Brevard Animal Welfare Collaboration Conference


Name of Organization_________________________________________________
Organization's Website________________________________________________
Board of Directors?  ___ yes  ___ no   Memberships?  ___ yes  ___ no
Contact Person:   Name______________________________________________
Phone_______________   Email_________________________
Type of Organization:   ___Government   ___Non-profit   ___Private (other than non-profit)   ___Commercial
What animal population do you serve?
    Domestic ___Cat   ___Dog   ___Bird   ___Reptile
___Other Small Animals (specify)________________________________
___Large Animals (specify)_____________________________________
___Other (specify)____________________________________________
Wild (specify)____________________________________________________
What Service(s) do you provide?
    ___Temporary Shelter ___Permanent Shelter
___Adoption ___Rescue ___Foster
___Low-cost Spay/Neuter ___No-cost Spay/Neuter
___Health Care
___Rehabilitation (physical or behavioral)
___Education ___Boarding ___Other
Would you be interested in collaborating with other animal organizations to develop a strategic plan to achieve No-Kill on Brevard County?   ___yes   ___no

Would you be interested in being part of a coalition applying for grants to help achieve No-Kill? (See for example, Maddie's Fund at   ___yes   ___no

Would you be interested in having your organization's contact information (and/or link to your website) included in a database on a central website, such as the BASE website and Brevard ASAP's website?   ___yes   ___no