Please fill out the form below to verify you qualify & Register for our Vaccine & Microchip Clinic. Name * First Name Last Name Email * Phone * (###) ### #### Home Address * No PO Boxes Address 1 Address 2 City State/Province Zip/Postal Code Country Number of dogs I need to get vaccinated and/or microchipped. * 0 1 2 3 - this is our max amount of dogs for a family at one time. Number of cats I need to get vaccinated and/or microchipped. * 0 1 2 3 - this is our max amount of cats for a family at one time. I confirm that I am under the poverty line in WA/ID or am facing significant financial hardship, making me unable to afford these services otherwise * You may be asked to show proof of this day of. Yes No I confirm I am the legal owner of the pet and provide accurate information about their health and behavior. * Yes No I understand that services are provided on a first come, first served basis, and there is no guarantee that my pet will receive services. * Yes No I agree and affirm that my pet has never been declared dangerous, potentially dangerous, or vicious in any state or jurisdiction. * Yes No I agree to keep my dog or cat on a leash or in a carrier at all times and ensure they remain under control during the clinic. If my dog may not do well around crowds of people and other animals, I will plan accordingly and take appropriate precautions. I understand that I am responsible for my pet’s behavior and safety, as well as the safety of others. Additionally, I agree to indemnify and hold harmless WCHS from any claims arising from my pet’s actions or behavior during the clinic. * Yes No I consent to the vaccination and/or microchip procedures for my pet. I understand that Whitman County Humane Society (WCHS) takes all reasonable precautions to ensure the safety and well-being of animals in the clinic, including oversight by a licensed veterinarian. However, I release WCHS from any liability for injury, illness, or loss related to my pet’s participation in the clinic in case of an adverse reaction, pre-existing health conditions, or any unforeseen complications. * Yes No By participating in the event, I grant permission for Banfield Foundation, Banfield Pet Hospital, Whitman County Humane Society, and MMI to use any photos or stories collected during the event for promotional, educational, or other authorized purposes. * I agree Thank you!
