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This application is for a one year membership to the Hand in Paw Kid's Club. 


Please contact afaulk@hssaz.org  (520.327.6088 ext 171) with any questions. To submit any supplemental information, please email it to the above listed email, mail to 635 W Roger Rd, Tucson AZ 85705, OR fax to 520.325.7190. 

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* 1. Please provide the following information

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* 2. Please check all that apply:
If you are required to show documentation as listed below, your child's membership will not be processed until the appropriated documents are provided. 

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* 3. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above. Your child's membership will not be processed until this documentation is received. 

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* 4. Please give us a brief description of your scholarship need.

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* 5. Please review and acknowledge the following statement:

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* 6. In case of emergency, please notify (persons other than parent(s)/guardian(s) - please include first and last name, relationship to child and phone number.

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* 7. Please list all persons responsible for picking up child including parent(s)/guardian(s). (For security reasons, no child will be released to any person not listed on this sheet.)

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* 8. Please list any person(s) who MAY NOT have contact with this child.

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* 10. Does your child have any existing medical conditions that we should be informed of? If yes, please explain.

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* 11. Is your child on any medication that causes side-effects our staff should know about? If yes, please explain.

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* 12. Does your child have any allergies to food, plant, animal or any other substances? If yes, please explain.

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* 13. Does your child have any mental or physical handicaps that require specific attention? If yes, please explain.

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* 14. Does your child have any dietary needs or restrictions? If yes, please explain.

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* 15. Child's Doctor / Physician including phone number

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* 16. Hospital Preference

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* 17. HSSA is an organization that serves the public and utilizes programmatic photos and video to advertise and educate our community.

I hereby authorize the Humane Society of Southern Arizona, Inc., to photograph and use my or my child or my pet's photographic image for the purpose of education, training, publicity and/or public information in the interest of providing better and safer homes for animals in my community. I understand that these images may be used in the public forum on a local, statewide or national basis. I understand that these images may be used in a variety of mediums, including but not limited to printed materials, internet websites, social media, slide presentations, videos and related media. If you have a safety concern, please contact afaulk@hssaz.org for exemption. 

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* 18. In exchange for my being allowed to participate in this educational program as provided through the Humane Society of Southern Arizona (“HSSA”), I waive any claim, cause of action, charge, liability, loss, cost, damage, fees (including attorneys’ fees) or expense of any nature which I may have or incur against HSSA, or against its members, directors, officers, employees or agents (“third party beneficiaries”) arising out of or in connection with my , my child’s, or my dog’s participation in the education program in which I have enrolled. Further, to the fullest extent permitted by law, I indemnify and agree to hold harmless HSSA and third party beneficiaries from and against any and all claims, causes of action, damages, losses, expenses, charges, fees (including attorneys’ fees) and liability of any nature arising out of or resulting from my participation or that of my dog in such training classes. In the event that any action or proceeding is brought or claim is made against HSSA or HSSA employees, HSSA volunteers, and HSSA Board of Directors, arising out of or in connection with my, my child’s, or my dog’s participation, I agree to resist and defend such action, claim or proceeding on behalf of HSSA or the third party beneficiaries by counsel designated by HSSA. Should an emergency arise, I give my permission for HSSA staff to render basic first aid and/or contact appropriate emergency services. 

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