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WE WILL NOT BE ACCEPTING NEW APPLICATIONS AT THIS TIME
Today's Date:
How did you hear about H.A.N.D.?
Do you have your written estimate from your vet?YES NO
REMEMBER, we cannot accept your application until an estimate has been received, unless there are special circumstances and we have already been notified of these special circumstances.
Based on advice from your vet, how urgent is it for your animal to receive care?
Very URGENT! Condition of my pet is critical!
Not critical, I still have time to raise funds
Not critical, but my animal is in pain.
Name of applicant: First Last:
Applicant's Street Address:
City StateZip code
Phone(include area code) Home: Cell
Work ExFax
H.A.N.D. relies on email for correspondence. If you do not have an email address and access to a computer, it really limits us in the way we can help you.
Your email address that you would like us to use: (please list the one you are able to check most often):
Are you employed?
Yes, I am employed
No, I am not employed, but I am looking for work
No, I am unable to work due to disability
No, I am retired.
What is the cost quoted on the estimate from the vet ?
What amount will you be contributing to your animal's care?
What is the total amount you are asking from H.A.N.D.?
If this is not your first application to H.A.N.D., when did you apply last?
Have you applied to other sources for the help you need?NO YES : Who if Yes
Do you have a low cost spay/neuter certificate? NO YES Already Altered
(must have animal Altered in order to receive MFA - Click here to see about getting a low cost spay/neuter certificate)
About the Homeless Animal
CanineFelineOtherGender? Male Female Animal's Age
Description of Animal
Where did you find this animal?
If the animal came from a shelter or rescue - please list
Is the animal:
Current on rabies?
Current on DHLPP shots?
Spayed or neutered?
On Heartworm preventative?
How many other animals do you have?
What is the diagnosis of the medical problem your pet has that has you seeking assistance from H.A.N.D.? Please be specific and enter all the information you can in the space below:
Do you already have an appointment scheduled for this veterinary care? YESNO
What is the prognosis for this animal after receiving care for this diagnosis? How will the animal be after receiving treatment/care? Please give all the details you can in the space below:
Does this animal have any other medical condition(s)? Please be specific and give all the information you can in the space provided below
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About your Veterinarian
Name of Vet
Name of Vet Clinic or Hospital:
Name of Contact person there:
Street Address
City State Zip Code
Phone Ex. Fax
Your Animal's Page
If your application is approved, we will be putting a page up for them on H.A.N.D., and possibly the front page of our website in order to seek donations for your pet's care. The story that goes on your pet's page will be what you enter in the space below. We suggest you make your animal's story unique, and describe them in the best possible light, and why you need help. Give the animal's name, where you got them, how long you have had him/her, what special things your animal does , and most of all, why do you need financial assistance at this time for this animal's care?
How will you be sending your photo of your animal? Email Postal mail
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