Pawsitively Seniors Application

PROGRAM OVERVIEW

Pawsitively Seniors is designed for low-income senior adults whose quality of life would be enhanced as a result of the many positive effects of pet ownership; by matching senior cats and senior people for the mutual benefit of all. Qualified seniors will be able to have one or two cats on the program. Seniors are defined as 60 and over with an income of $1800 per month or less. Senior cats are defined as 8 years and older, who have been spayed/neutered and are current on vaccinations, Felv and FIV tested and are negative, microchipped and in general good health, and cats with special needs who have manageable behavioral or medical issues. The Pawsitively Seniors program includes:

Free food and litter delivered on a regular schedule, if needed.
Free medical care from a program approved veterinarian.
Free transportation to and from a program approved veterinarian.

Please indicate next to each statement that you have read and agree:

When I initially apply, I am allowed a maximum of 2 pets on the program. *

PALnv will provide pet food and cat litter, if needed, each month. A PALnv volunteer will deliver the food and check on the cat's needs. *

A program-approved veterinarian will provide veterinary care at no cost at their Wellness Clinic (within their discretion - quality of life and prognosis will be considered). *

I hereby agree to release PALnv and our partners, their programs, Board of Directors, staff, volunteers, donors, contractors and affiliated organizations from any and all liability. *

I agree not to use social media or any media outlets to make statements that would in any way damage or negatively impact the reputation of PALnv and their partneres. *

In the event my current situation changes, I will immediately notify PALnv. *

I understand I will be contacted and reminded about the delivery date. I commit to be present in the agreed-upon location the day of the delivery. *

Today's Date: *

First Name: *

Last Name: *

Phone Number: *

Address/Building/Apartment #: *

City: *

State: *

Zip Code: *

Mailing Address, if Different:

Email Address: *

Emergency contact name (if we can't reach you): *

Emergency contact phone number:

How many people live in the home? *

Please list the ages and relationship of all others who live in your home. (Please list names and relationship to you i.e. son, daughter, husband, etc.) *

Household monthly income (total income of all living in the home): $ *

How did you hear about us? *

The following information will be used exclusively to obtain grants and funding for our Pawsitively Seniors Program.

Year of Birth: *

Gender: *

Are you a United States Veteran? *

Are you disabled? *

What ethnicity do you most identify as? *

A copy of the following documents must be submitted with your application.

Proof of income:

Last 2 months of bank statements or last two months of pay statements or your most current tax return or SSI Letter.
Proof of Residency: current utility bill or NV ID or NV driver’s license
Proof of Military Service (if a veteran): DD Form 214

Please email the above documents to: info@palnv.org

OR

Mail to: PALNV, 4155 N Rancho Drive #150, Las Vegas NV 89130

Agreement

I certify that all information I provided is true and correct to the best of my knowledge.

Date: *

Applicant Signature: *

On touchscreen, sign with your fingertip or stylus. On PC, sign with your mouse. Click Submit when you are finished with the application. Then check your email for a confirmation message.

Note: All fields with a red * must be completed.

Neither PALnv or their volunteers will discriminate against any clients or family members in the operation of its program on the basis of race; color; national origin, including limited English proficiency; sex; age; political affiliation; religion; or on the basis of disability, or sexual orientation.

Our Rights:

We reserve the right to refuse service to anyone.