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Please complete the following information regarding you and your pet:
Tell Us About Yourself
*
Indicates required field
Name
*
First
Last
Age
*
0 to 17
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or more
Ethnicity
*
White
Asian
American Indian
Black or African American
Middle Eastern or North African
Hispanic Latino or Spanish origin
Native Hawaiian or Other Pacific Islander
Other
Gender
*
Female
Male
Transgender
Prefer not to say
Other
*
Marital Status
*
Married
Single
Divorced
Widowed
Other
*
Household Income
*
$0 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or more
Education
*
Some High School
High School
Bachelor's Degree
Master's Degree
Ph.D. or higher
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Primary Phone
*
Email
*
Active Duty or Veteran & list your Rank (note if retired)
*
Military Branch & Base
*
How did you hear about us (if it's a veterinary clinic, specify which one)?
*
Please provide a detailed description of what's wrong with your pet and what your concerns are
*
Explain why you are unable to cover the costs for your pet.
*
Tell us about your military service (i.e. years served, any deployments or achievements):
*
Tell Us About Your Pet
Pet's Name
*
Age
*
Breed
*
Pet's Sex
*
Male
Female
Weight
*
Are you able to pledge a recurring donation each month to Helping Paws? If so, how much?
*
Click here to make your pledge
I declare that I have exhausted all alternative options to me for financial assistance and I agree to (initial next to agreed upon term):
I agree to reimburse Helping Paws for any funds received upon a change in my financial circumstances.
*
I agree to fill out a testimonial after treatment in order to receive a grant
*
I authorize Helping Paws to use my and/or my pet’s photograph, video and any information relating to his or her procedure and outcome. This is required for fundraising purposes. Please notify us if you are unable to agree to this.
*
Upload a photo of you/your family, and your pet in need (if possible, please include one of you in uniform with him/her)
*
Max file size: 20MB
Upload a current photo of your pet (additional photos can be emailed to
[email protected]
)
*
Max file size: 20MB
I hereby contest that:
- I do not own or operate any form of for-profit breeding or pet shop.
- I understand that these funds are to be used at a participating Helping Paws veterinary hospital.
- I understand that Helping Paws is not responsible for the treatment and/or outcome of any veterinary services provided and hereby waive all claims of liability against the Helping Paws charitable fund.
- I understand that Helping Paws reserves the right to deny a request for financial assistance to anyone for any reason.
- I declare, under perjury, that the foregoing is true and correct to the best of my knowledge.
Full Name as Signature
*
Date
*
*Upon completion, all adults in the house will need to apply for Care Credit and send the response to us at
[email protected]
. Once you hit submit, read the confirmation page for instructions and check your spam file if you don't receive an email from us.
Please click the "
Submit
" button
once
. Thank you!
Submit
Home
About Us
Our Mission and Vision
Our Founder
Board of Directors
Leadership Team
IRS Forms, Founding Documents & Financials
Apply for Help
Get Involved
Events
How to Help
Our Sponsors
Volunteer
Shop
Our Impact
Videos
Stories
Press
Write a Testimony
Help Agencies
Help Agencies
Contact Us
Contact Us
Become a Participating Hospital
Donate
Support Us