Hello world! - Harley's Hope Foundation

Are you a Colorado resident?

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Are you a military veteran?*

Yes

No

Has this pet been a member of your household for a minimum of six weeks?

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Veterinary information

Do you have an established relationship with a veterinary clinic?*

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Is this a major or emergency situation?*

HHF does not fund preventative/routine care.

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Do you have a diagnosis, survival prognosis, and estimate for treatment?*

All applications must include veterinary notes with the information stated above. HHF does not pay to get an animal seen by a veterinarian or for tests to determine what is wrong.

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Are you able to secure funding up and above what HHF may offer if you are approved for assistance?*

HHF caps its assistance at $500 per case. Payment is made directly to the veterinary clinic. No one is guaranteed the maximum award, so you must be applying to other charities and attempting to raise funds yourself

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Contact information

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Financial information

Total household income:*

Include income for all adults 18 and over living in the home. Enter "0" if you have no income.

Please clarify how you are paying for rent, food, etc.

Please explain how you are paying for rent, food, etc.

Are you employed?*

Yes

No

Employer name

Latest Paycheck Stub

Please black-out any sensitive information like your SSN from your financial documents. If you are unable to upload this information, please email a copy to petcare@harleys-hopefoundation.org or call 719-495-6083 to make alternative arrangements.

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 100 MB.

Are you receiving public assistance of any type?

This includes food stamps, housing assistance, Medicaid, and other assistance based on proof of financial need

Yes

No

Please upload proof of public assistance and/or financial need

Please black out any sensitive information like your SSN from your financial documents. Please black-out any sensitive information like your SSN from your financial documents. If you are unable to upload this information, please email a copy to petcare@harleys-hopefoundation.org or call 719-495-6083 to make alternative arrangements.

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 50 MB.

What is your primary source of income?*

This includes work income, Social Security, Social Security Disability Income, pension, etc.

Additional sources of assistance

How many people live in the household other than the applicant? How many are adults?*

Do all adults work? If no, why not?

Do you own your home/car?*

Yes

No

Are you able to borrow against your home or car to pay for veterinary care?

Yes

No

Not Sure

Have you asked family and friends to assist with your pet's veterinary needs? If no, why not?*

Have you or will you sell belongings to pay for veterinary care? If no, why not?*

Care Credit*

All applicants must apply for Care Credit. If you have been declined, please include the declination date and email. If you have been approved, please indicate the amount approved. You must exhaust all Care Credit before HHF funding would be released.

Care Credit

Date of Approval/Denial

$ Received

List all other charities you have applied to for assistance and the amount received, if any.

A listing of veterinary assistance charities may be found under the Pet Resources

Organization name

Date of Approval/Denial

$ Received

Pet information

Pet's Name*

Species*

(dog, cat, horse, rabbit, etc.)

Breed

(type of dog, i.e., Lab, Poodle, etc. For cats, Siamese, Calico, etc. )

For the next question, listing underlying health issues will not necessarily eliminate you from consideration. However, if you fail to list your pet's health issues, and those issues negatively impact your pet's outcome, HHF will reserve the right to take legal action to recoup any grant funds paid out on your case. If there are no underlying health issues, enter "None" in the block.

Please list any/all of your pet's underlying health issues, even those that are not related to your current issue.*

Is this a medical service animal as defined by the Americans with Disabilities Act*

Click here for the definition of a medical service animal

Yes

No

Gender*

Male

Female

Pets age*

Age is ...*

Months

Years

Is the pet spayed or neutered?*

All pets over the age of one year must be spayed or neutered in order to qualify for our program

Yes

No

We are sorry, but you do not meet our program guidelines. Please visit our Pet Resources page for a listing of other veterinary assistance programs.

Describe your pet's veterinary issue:*

If you are applying for help for an injury to your pet, please explain in detail how the injury occurred.

Has this animal been seen by a veterinarian?*

Yes

No

Name of veterinarian clinic*

Phone number for veterinarian clinic*

Veterinarian clinic address

Street Address Address Line 2 City State ZIP Code

Date animal was seen at this clinic:*

Estimated cost for treatment:

Upload veterinarian documentation

If you are unable to upload this information, please email a copy to petcare@harleys-hopefoundation.org or call 719-495-6083 to make alternative arrangements.

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Harley's Hope requires all funding recipients to:

Upon accepting HHF's financial assistance with veterinary care, you agree to immediately notify the attending veterinarian that they may share any/all of your pet's health information and records with an HHF representative.
Upon accepting HHF's financial assistance with veterinary care, you agree to NOT euthanize your pet unless the attending veterinarian states that there is nothing more to be done and that your pet is suffering. We will require your veterinarian's note attesting to this. If a pet HHF has approved for care is euthanized instead, and if the client cannot produce a note from the veterinarian stating that this action was called for, HHF reserves the right to take legal action to recoup any funds paid out on your case.
Grant permission to use your photo and your pet's photo and story in fundraising and marketing materials.
Write a brief testimonial regarding what it meant to you to receive assistance from HHF.
Consider a future donation to Harley's Hope when your financial situation improves.
Agree to participate in follow-up phone calls or emails from an HHF volunteer shortly after treatment and at 6 months post-treatment. Updated photos of your pet will be requested at this time.
Agree to inform HHF if your address or phone number changes during the 6-month post-assistance period.

Do you agree to all requirements:*

Yes

Terms and Conditions*

I hereby certify that the answers on this application are true and correct and understand if I willing provide false information, HHF will take legal action to recoup the funding obtained under fraudulent means. Furthermore, I agree to release Harley's Hope and its service providers, volunteers, and other representatives, from liability should the care rendered is unsuccessful or should my pet become injured while in emergency foster care.

Signature of pet's legal guardian*

CAPTCHA

Application for Major/Emergency Veterinary Assistance

Veterinary information

Contact information

Financial information

Additional sources of assistance

Pet information

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