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About Harley’s Hope
Pet’s We’ve Helped
Request For Services Application
Only complete applications will be reviewed.
"
*
" indicates required fields
Step
1
of
7
14%
Are you a Colorado resident?
*
Yes
No
Are you over 50 years old?
*
Yes
No
Are you a military veteran?
*
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.
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.
Contact information
Name
*
First
Last
Email
Phone
*
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.
Are you employed?
*
Yes
No
Employer name
Financial Documentation
Please upload your latest paycheck stub here. If you are not working, please upload a proof of financial need here, such as a recent bank statement, proof that you are receiving government assistance of some sort, or if Social Security or Social Security Disability is your source of income, you may upload a copy of your award letter. *** Please black-out any sensitive information like your SSN from your financial documents.***
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: 100 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?
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?
*
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
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.
*
Gender
*
Male
Female
Pets age
*
Please enter a number from
1
to
99
.
Age Is...
*
Months
Years
Is the pet spayed or neutered?
*
Yes
No
Upload One Or More Recent Photos Of Your Pet
Drop files here or
Select files
Accepted file types: jpg, gif, png, tif, jpeg, Max. file size: 150 MB, Max. files: 5.
Photo Request Acknowledgement
Photos will be used on our website and social media. They should be clear, not blurry, and should feature the animal we're helping without other animals in the photo and minimal clutter in the background. Ideally, we want you in the photo with the animal given that our mission is to keep pets and people together. We want to show that human-animal bond exists and is important to preserve. Because of this, please do not send pictures where the animal is halfway across the room from you and where there is no interaction between the two of you. We want to see how much you care about your pet.
Photos should be hi-resolution, 300 dpi is good (you should be able to set this resolution on your cell phone), and ideally taken in a horizontal format (turn the cell phone sideways) as it allows us to use the whole image. Thumbnail size photos will not be accepted because we can't enlarge those without pixelation.
If you are seeking help with a condition that is obvious - broken leg, eye issues, etc. - the before photo should show what is wrong. If the photo is deemed too gory for Facebook, we will ask for a second photo at that time. If your pet is suffering from an internal condition - bladder stones, cancer, etc., then please just send a good, clear image of your animal following the guidelines listed above. People want to see evidence of what we are doing and why - it goes back to making the case for the importance of what we do. Glamour shots of your pet show a perfectly healthy animal who doesn't appear to need our assistance. I know clients are prone to want to show off their pretty pets, but those photos do not represent the urgency of our mission.
I understand this photo request.
Select the services needed. Harley's Hope makes no guarantee that we can help with multiple services due to the volume of applications received, and the cap on financial awards.
Veterinary Care Assistance
Louis Steinwedel Memorial Pet Cancer Fund
In-Home Pet Care
Pet Food Support
Emergency Boarding / Foster Care
Pet Deposits
Transportation
Select All
Veterinary Care Assistance Information
Is this a major or emergency situation?
*
Yes
No
Do you have a diagnosis, survival prognosis, and estimate for treatment?
*
Yes
No
Are you able to secure funding up to and above what HHF may offer if you are approved for assistance?
*
Yes
No
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.
Are you applying for medication assistance only? If so, please list the medication, the dosage, the condition for which your pet is being medicated, and the name and contact information for the prescribing veterinarian.
Has this animal been seen by a veterinarian?
*
Yes
No
Why has this animal not been seen by a vet?
Name of veterinarian clinic
Phone number for veterinarian clinic
Veterinarian clinic address
Street Address
Address Line 2
City
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
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.
Cancer Care Assistance Information
Do you have a diagnosis and estimate for treatment?
Yes
No
Are you able to secure funding up and above what Harley’s Hope may offer if approved for assistance?
Yes
No
Describe your pet’s cancer diagnosis and when the diagnosis was made.
Is your animal being seen by a veterinary cancer specialist?
Yes
No
Is your regular veterinarian referring you out to a cancer specialist?
Yes
No
Please list the name, address and phone number for the clinic where your pet will undergo treatment for his/her cancer.
Please attach copies of all veterinary paperwork you received to this application.
Drop files here or
Select files
Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 50 MB.
Estimated cost for treatment.
How much of the estimate are you able to cover?
Have you applied for assistance from other veterinary assistance funds?
Yes
No
How much, if any, have you received or been approved for?
Please visit the online Pet Care Resource Directory, under the Pet Resources tab on our website, for a listing of other cancer assistance organizations.
In-Home Pet Care Information
Harley's Hope offers in-home pet care of animals whose people are hospitalized or incapacitated.
Please explain why you need in-home pet care assistance
Please list the number and size of all cats, dogs and other pets along with the type of food needed for each (wet, dry or both).
Assistance Start Date
MM slash DD slash YYYY
Assistance End Date (if known)
MM slash DD slash YYYY
Can you provide proof of current vaccinations for all affected pets?
Yes
No
If you will be/are incapacitated, do you consent to allow a reputable third-party company to enter your home to provide the requested pet care?
Yes
No
Pet Food Support
What type of pet food is needed (dry cat food, etc)?
Please list the number and size of all cats, dogs and other pets along with the type of food needed for each (wet, dry or both).
List any other items needed for the pets (litter, etc).
Emergency Boarding / Foster Care Information
Harley's Hope offers emergency boarding and foster care of animals whose people are hospitalized or incapacitated.
Please explain why you need emergency boarding / foster care assistance
Assistance Start Date
MM slash DD slash YYYY
Assistance End Date (if known)
MM slash DD slash YYYY
Please list all other pets in the household affected by this request. List number, types of pets, names, and ages.
Can you provide proof of current vaccinations for all affected pets?
Yes
No
Pet Deposits
Why are you moving?
Type of pets moving with you (cats, dogs, etc).
When are you moving?
MM slash DD slash YYYY
Amount needed for the pet deposit?
Name and contact information for new landlord.
Transportation
When is transportation needed?
MM slash DD slash YYYY
Pick-up address
Destination address
Types of pets are being transported.
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. 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
Consent
I agree to the privacy policy.
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