BARRC Free Dog Sterilisation Program

Please note that submitting a sterilisation request does not guarantee that an animal will be sterilised. This program has limited funding available and is accessible to persons suffering financial hardship only. BARRC makes every effort to sterilise as many animals as possible with the funds available. Bookings are subject to confirmation by BARRC and completion of this form. If you require this service for more than one dog, please complete one application form per dog. A $40 refundable deposit is required to secure your booking. You must apply for assistance and receive your voucher BEFORE you take your pet to the vet.
To ensure we can verify your application meets the requirement of the program, please state where you hear about this program? (eg Name of Shire Ranger Service; Name of Vet Clinic; RSPCA Referal) *	RSPCA Vet Clinic (provide clinic name) Shire/Council Ranger Service (provide shire)
If you checked Shire/Council or Vet Clinic above, please provide name of shire or clinic.
Details of Animal
Name of Animal *
Sex of Animal *
Breed of Animal *
Weight of Animal in kg (estimate)
Age of Animal *
Colour of Animal *
Is this dog microchipped? *
Please provide microchip number if known
Microchipping is a mandatory requirement. If your dog is not already microchipped please check the 'I Agree' box to receive a FREE microchip at time of sterilisation procedure. Note: This service is ONLY available to participants in the sterilisation program.
	I Agree
Does the dog have any health issues or had any previous procedures/treatment? *
If Yes, please provide details Remember to also include any medication/treatment that the animal is currently taking or requires long term.
Is your dog currently on any medication? *
If yes, please provide details of medication (name and dosage)
Please select only one preferred vet location *	Bunbury Bridgetown Clarkson Collie Eaton Manjimup Mount Barker Narrogin Port Kennedy
Owner Details
First Name *
Surname *
Street Address *
Town or City *
Postcode *
Email *
Phone *
Please provide proof of identification. Photo of Driver’s Licence; Household Services Bill (in your name at current address); Council Rates; Centrelink Concession Card; Medicare Card *
Declaration By signing this Application Form, I agree to the following:
I declare that I am the owner of the animal identified in this application and that no other person has a proprietary interest in the animal. I agree to indemnify BARRC against any claims or liabilities arising from my participation in the Free Dog Sterilisation Program.
I confirm that I am 18 years of over.
I understand that if there are any special circumstances (e.g. if my dog is pregnant or in season, male dog has retained testicles, etc.) I am liable for additional costs that are not covered by BARRC.
I understand that if any complications occur (e.g. post-operative infection, anaesthetic reaction, etc.) and my pet needs treatment post-surgery, I am liable for additional costs that are not covered by BARRC.
I confirm that all information provided is accurate, truthful and correct to the best of my knowledge.
I acknowledge the above and fully release BARRC and its volunteers and agents from all liability in connection with my participation in the Free Dog Sterilisation Program.
I agree to providing a $40 refundable deposit within 7 days of confirmation of acceptance for the program and understand that cash refunds will not be permitted.
Please provide your account details for refund of deposit.
Name on Bank Account: *
BSB: *
Account Number: *
Once your application has been approved, you will be issued with a unique voucher code. At each stage of the process you will receive an email to the address provided on this form. Please note response time can take up to 7 working days.
SIGNATURE Required. Note: If using computer, hold mouse left click and sign. * If an error is made, you can simply select the 'clear' button and recommence your signature.
Dated *
Please ensure all mandatory fields are completed and that the form is signed and dated before hitting the 'Submit' button at the base of this form.