ACO Special Assistance Fund Online Application CHS may utlize community veterinary partners to provide treatment for animal control pets when funding is available. Town:(Required) Officer:(Required) Pet Name:(Required) Breed:(Required) Age:(Required) How long has this pet been in your care?(Required) How did this pet come to you?(Required) SURRENDER STRAY CONFISCATED/SEIZED Other Does this pet already have an adopter lined up?(Required) YES NO Is this pet up-to-date with vaccinations?(Required) YES NO If no, why?(Required) Please describe any illnesses or injuries this pet may be currently showing:(Required)Has this pet ever shown aggression toward people or animals?(Required) YES NO If yes, please describe:(Required)What treatments(s) does this pet need?(Required) Why are you requesting assistance for this pet?(Required) How much are you able to contribute toward this care?(Required) Please describe how provision of this support will benefit the pet in finding placement?(Required)Medical Records & Pet PhotosUpload all medical records, estimates, and bills you have relative to this funding request.(Required) Drop files here or Select files Max. file size: 256 MB. Please upload 2-3 photographs of your pet.(Required) Drop files here or Select files Max. file size: 256 MB. Sharing the good work of CT Humane Society is key to inspiring the community to support this program and make it available for pets in need. CT Humane Society may use photos of this pet(s) and their name(s) for this purpose. We will not use confidential legal guardian information, like your name without your consent. Will you allow CHS to use photos of you and /or this pet for promotional purposes?(Required) YES NO By signing, I attest that I have legal guardianship of the above pet and that the information provided on this application is true and accurate to the best of my knowledge.Signature(Required)First and Last NameFirst NameNoneDate(Required) MM slash DD slash YYYY
