Please Help!

 

Handicapped Pets Foundation Grant Application

The mission of the Handicapped Pets Foundation is to support caretakers of elderly, disabled, and special needs pets with the equipment, especially dog wheelchairs, they need to live happy, healthy lives. Assistance is provided for those people with a demonstrated financial need. Please note that you will have 30 minutes to complete the application form before the session will time out and you will have to re-submit the information

 

* All fields must be completed for the application to be considered.

About You

Applicant First Name *
Applicant Last Name *
Mailing Address *
City *
State *
Zip Code *
Day Phone *
(Example: 999-999-9999)
Alternate Phone
(Example: 999-999-9999)
E-mail Address
Rescue Group
Your affiliation with group
 
Have you ever received a Handicapped Pets Foundation Grant? *       Yes    No
If so, when?      (Example: m/d/yyyy)
How did you hear about us? *     
If other, please specify     


About the Animal

Animal Name *
Species *
    If other 
Breed
Age *
Sex *
  Male   Female
Spayed/Neutered? *
  Yes    No
If not, what are your plans to have this done?
When did you acquire the animal? *
(Example: m/d/yyyy)
Describe the circumstances of where this animal came from, and how s/he became the responsibility of the applicant. *
Plans for animal *


About the Animal's Injury or Illness and Treatment

Does this case involve animal cruelty charges? *      Yes    No
If so, please indicate the police department and report number:
Police Department
Report Number
Describe the animal's injury or illness. Include a description of the injury or illness, how long the animal has been sick or injured and the cause of the injury or illness. *
Indicate the specific equipment and/or treatment needed, the urgency of the treatment and any follow-up care required. *
What is the estimated total cost of treatment and equipment? *
 $
How much are you able to personally contribute? *
 $
How much have you received from other donations? *
 $
List any donations you have received for the treatment of this animal.
Include the name of the contributing organization(s) and the amount of their donation(s).
Describe your financial hardship and sources of local, state, and federal aid you are receiving (ex. food stamps, unemployment, other). *


About the Clinic Treating the Animal

Clinic Name *
Clinic Address *
Clinic City *
Clinic State *
Clinic Zip Code *
Clinic Phone *
(Example: 999-999-9999)
Clinic Fax
(Example: 999-999-9999)
Contact Name



Applications will only be processed when you click "Submit Application." No applications will be processed via mail or fax.

  
Submit
Joomla Professional Work