Request for Financial Assistance | Senior Dog Haven & Hospice

Your Information

Your Name

Address

City

State

Zip Code

Phone Number

Email

Dog Information

Name of Dog

Age of Dog

Breed of Dog

Where did you get your dog?

How long have you had your dog?

Description of your dog’s need:

(Please include as many details as possible):

What steps have you taken to try to address your dog’s need?

Please explain reason for financial hardship:

Are you able to contribute any dollar amount to your pet’s care? If not, can you please explain why?

What plan do you have in place to provide your pet ongoing care after this financial assistance is received?

f you have proof of your current financial hardship, please upload a copy:

Maximum upload size: 15MB

(Please upload in .jpeg/.jpg or .png format) This could be proof of fixed income or government assistance. The more information you are able to provide about your current financial hardship, the better able we are to prioritize your request

How did you learn about our program?

Are you willing to use our rescue’s vet?

Yes

No

Please upload a picture of your dog:

Maximum upload size: 15MB

Attestations

In the event we are able to provide financial assistance for your dog’s need, do you consent to us sharing your dog’s photo and story on our social media to fundraise for their vetting needs? Owner’s name and location will be kept anonymous.

Yes, I consent and agree.

In the event we are able to raise money for more than what your dog needs for their vetting, do you understand these funds will be used to help other owner assistance requests?

Yes

You understand Senior Dog Haven & Hospice or our vet partners cannot be held liable for the outcome of any medical procedures performed on your pet.

Yes