Rescue Contact *

First Name

Last Name

Gender *

Male

Female

Spayed/Neutered? *

Yes

No

Is the pet urinary incontinent? *

Yes

No

Is the pet fecal incontinent? *

Yes

No

What form of sponsorship are you applying for: *

Assistive Device (Cart, Wheelchair, Harness etc)

Supplies

Specialty Consult

Rehabilitation

Veterinary Care

By clicking agree and submitting this application I acknowledge the following: *

I have read Wild Hearts mission statement and application guidelines. If approved, I am willing to participate in press, stories and/or updates, which may include a member of Wild Hearts taking photos or videos in your home, at a veterinary clinic, rehabilitation facility or any other event pertaining to the sponsorship or submitting photos or videos as requested. If within an area where Wild Hearts has an established relationship with veterinary or rehabilitation services, I will take my pet to their preferred facility. I will acknowledge Wild Hearts sponsorship on Facebook, Twitter, Instagram or any other social media platform I have access to and share their mission. I will participate in all surveys Wild Hearts provides in order to evaluate and continue their mission. I give permission to Wild Hearts to contact my veterinarian regarding my pet and give consent to release records to them for review. All information provided within this application is true, correct, and complete, to the best of my knowledge.

Agree.