Assistance Request Form
FANS of WCRAS is 100% donation driven and using stories about what we do funds our ability to help people and their pets. Our stories use the name of the pet and photos or videos. The family's name is never used. By accepting assistance from us, you hereby grant FANS of WCRAS permission to use your story (anonymously), photograph(s), and/or video(s) in any and all of its publications or on the internet, whether now known or hereafter existing.  You will make no monetary or other claim against FANS of WCRAS for the use of the photograph(s) and/or video(s).  Please send at least 3 photos of your pet to for future use.
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Nameki *
Phone *
e-mail *
Address *
City, State, Zip Code *
Are you the owner of the animal? *
If you are not the owner, please type the owner's full name and address below. *
Referred by
Type of Assistance Requested: (NOTE: In most cases a written estimate is required, this can be emailed to *
Type of Pet *
Pet's name *
Explanation of the issue *
Do you qualify for Care Credit? *
How much money can you contribute towards the costs? *
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