Desexing and Microchipping Assistance Application

First Name *
Last Name *
Address *
City *
Post Code *
Home Phone
Cell Phone *
Email Address *
Dog's Name *
Dog's Age *
Dog's Sex *	Male Female
Dog's breed *
Desexed *	NoYes
Microchipped *	NoYes
Registered *	NoYes
If registered, what council?
Last Vaccinated *
Has your dog had any of the following symptoms in the past 7 days: Coughing, Vomiting, Diarrhoea, Lethargy *	NoYes
Has your dog or any other dogs on your property tested positive for Parvo Virus or have you had dogs on your property that have contracted the virus in the past three years *
Do you have a community services card? *	NoYes
What is your Community Services Card Number? You will need to bring your card with you if your application is approved. It will be scanned and put with your application.
Expiry date for Community Services Card
Income Source (include other household/family members) *
Where did you get your dog from? *
How long have you had your dog? *
Did you pay for your dog? *	NoYes
If yes, how much did you pay for your dog
How many dogs do you have? *
Please tell us about your other dogs. *
Do you have other pets? *
How does your dog behave in the car, meeting new people and at the vet? *
Why do you require assistance? *
Do you have transportation to go to the vet? *	NoYes
Do you have a regular vet? *	NoYes
Vet details if yes
When was the last time your dog went to the vet and why? *
When was your dog last on heat and or had puppies? (If applicable)
If your application is successful you will be required to contribute to the cost of the assistance. How much can you afford? *
Does your dog have allergies?	NoYes
If your dog has allergies what are they?
How did you hear about the Dogwatch Community Outreach Programs?
Do you have any other comments to add?
If you are looking to apply for food assistance you will need to complete a separate food assistance form, pending approval.	NoYes