Rescue Partners Program Enrollment Rescue InformationRescue Name(Required)501(c)3 numberState Animal Shelter License numberRescue Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Rescue Email Address(Required) Enter Email Confirm Email Select all that apply(Required) This is our billing email address This is our email address for appointment booking This is neither our billing or booking email address (I will provide those in the next section) Contact InformationPrimary Contact(Required) First Last Primary Phone(Required)Primary Contact Email, if different from above Enter Email Confirm Email Is this the billing contact? Yes No Is this the booking contact? Yes No Secondary Contact, if applicable First Last Secondary Contact's Phone, if applicableSecondary Contact Email, if applicable Is this the booking contact? Yes No Is this the billing contact? Yes No Consent & Liability WaiverProgram Enrollment Liability Waiver(Required)I, the below undersigned, being of legal age and the owner or legal custodian of the animals described above, hereby authorize the Animal Welfare Society Community Veterinary Clinic (“AWSCVC”), including its directors, employees, representatives, and volunteers, to receive, transport, prescribe and administer medications, medically examine and treat, perform sterilization surgery, and tattoo any animal brought through the Rescue Partners Program. I acknowledge that the AWSCVC will utilize generally accepted veterinary and husbandry practices in treating and caring for the animal. I acknowledge that the AWSCVC, including its directors, employees, representatives, and volunteers, shall not be liable for any injury, loss, escape, or destruction of the animal however caused or precipitated or for any injury or destruction caused by the animal to third parties and that I shall hold AWSCVC harmless and reimburse AWSCVC in full from any and all claims, demands, or judgments as a result of such injury, loss, escape, or destruction of the animal however caused or precipitated or for any such injury or destruction caused by the animal to third parties. If during the course of examination, treatment, or surgical procedure AWSCVC determines that additional medical treatment, procedure or surgery is reasonably required in the best interests of the animal’s health and welfare, then I authorize AWSCVC to provide such additional medical treatment, procedure or surgery. I understand that the sterilization surgical procedure shall be performed at the discretion of AWSCVC’s veterinary staff and that appropriate anesthetics will be utilized even where the animal may be a pregnant female. A refusal by AWSCVC veterinary staff to perform the sterilization surgical procedure, or any other surgical procedure, shall be at its sole discretion. I acknowledge that in the event that the animal becomes ill after the surgical procedure(s) authorized herein, I will return the animal to AWSCVC for examination and potential further treatment as soon as possible. In the event l bring the animal to another veterinarian or veterinary emergency facility, AWSCVC has the right to refuse reimbursement for such additional treatment. I acknowledge that the animal described herein must be picked up from AWSCVC at the designated pick-up time the same day of surgery. In the event that I do not claim the animal by such time, then I understand that the animal will be considered abandoned and AWSCVC will act appropriately and consistent with its procedures for handling abandoned animals. I understand that once the animal has been deemed abandoned, then I relinquish all right, title and legal interest in the animal but that I will be held responsible for all medical and boarding expenses incurred up to the time of abandonment and for any such additional medical and boarding expenses incurred thereafter in the event that I attempt to reclaim the animal. I consent
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