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Application for Major/Emergency Veterinary Assistance
"
*
" indicates required fields
Step
1
of
9
11%
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
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Add
Remove
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. )
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:
*
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
ZIP Code
Date animal was seen at this clinic:
*
MM slash DD slash YYYY
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.
Please list other pets in the household:
Are all other pets spayed or neutered and current on vaccinations:
Yes
No
If applying for a cat, is this an indoor cat or outdoor cat?
We cannot take cases for outdoor cats, and If it is an indoor cat and the injury or illness was caused by them being allowed out, we also cannot take the case.
Indoor
Outdoor
If applying for a dog, is the dog kept inside as a family member or do they sleep/live outdoors?
*
If outdoors only, we will not take the case
Indoor
Outdoor
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 your dog kept chained?
*
Dogs tethered for short periods of time to do their business are eligible. Dogs that spend long periods chained up are not being treated as family members and we will not take the case
Yes
No
Does your dog ride unrestrained in the back of a truck?
If yes, we will not take the case due to the high risk of injury/death caused by this scenario
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.
If your pet's injury or illness was caused by unsafe conditions in your home or yard, are you willing to immediately correct those conditions?
Yes
No
Do you provide your pet with regular care including annual check-ups, periodic dental cleanings, and keep their vaccinations current?
Pets must have been seen by a veterinarian within the last two years to qualify for assistance. Animals age must faster than humans and even going two years without an exam is the equivalent of humans not seeing a doctor or dentist for approximately 7 years.
Yes
No
If unable to care for your pet or unable to secure funding for this emergency, are you willing to surrender your pet to another responsible party that can provide care?
Yes
No
Harley's Hope requires all funding recipients to:
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
*
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