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Harley's Hope Foundation   ©   2010 - 2017   •  All Rights Reserved

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To read about the animals we've helped, please visit our Facebook & Twitter pages.
Complete the application in its entirety and provide the following:

•  Proof of financial need (recent paystub, recent bank statement, SSI/SSDI award letter, food stamp card, other public assistance cards or award letters. Be sure to block out your Social Security Number.)
•  Behavioral assessment and training plan
•  Itemized estimate.
•  Digital photo of your pet.


Applications that are not complete or are not accompanied by the required documentation will not be reviewed.
You must submit all the required documentation within 24 hours after you submit your application or your application will be declined.

Submit your application:
•  Online at http://www.harleys-hopefoundation.org/trainingassistanceapplication.html (If you submit your application online but are unable to upload documents, you may email or fax them.)
•  Or Email to services@harleys-hopefoundation.org
•  Or Fax to (719) 495-5945
QUALIFICATION SURVEY:
  YES NO
• Have you sought assistance and advice from a behaviorist/trainer?
All eligible clients must show proof that they have attempted to seek assistance for the behavioral issue before applying.
     
• Do you have a training plan and estimated cost?
All applications must be accompanied by the behaviorist/trainers providing this information.

If you have answered “No” to any of the qualification survey questions, do not submit your application.

Do not leave any questions blank. If the question does not apply, answer “n/a”

 

CLIENT INFORMATION:
Name
Address
City
State
Zipcode
Phone Number
Email Address
   
Total Household Income:
(Include significant other/spouse's income)
Employed? Yes    No
Hours per week:
PLEASE UPLOAD YOUR LATEST PAYCHECK STUB HERE:

OR EMAIL YOUR LATEST PAYCHECK STUB TO services@harleys-hopefoundation.org

Name of Employer:
Address of Employer:
   
Are you receiving public assistance of any type? Yes    No
What kind?  Amount: Frequency:
Please UPLOAD Proof of Public Assistance and/or Financial Need HERE:

OR Email Proof of Public Assistance and/or Financial Need TO services@harleys-hopefoundation.org

What is your primary source of income? 
   
How many other people live in the household?
How many are adults?
Do adults work? Yes    No
If not, why not?
Do you own or rent your home? Own    Rent
Do you own a vehicle? Yes    No
Have you asked family/friends to help with your pet's training assistance? Yes    No
If yes, why can't/wont' they help?
Have you or will you consider selling belongings/assets to pay for training assistance? Yes    No
If not, why not?
   
Have you requested financial assistance from other agencies, including Care Credit, credit cards, or individuals to treat this particular issue? You must have exhausted all other options prior to applying to Harley's Hope Foundation. Please indicate to whom you have applied, the date of approval or denial and any monies received.
Individual/Organization Date of Approval/Denial $ Received



PET INFORMATION:
Name of Pet
Species:
Breed:
Gender: Male  Female
Age
Spayed/Neutered? Yes   No
* Service Animal? Yes    No
*Based on the definition under Title II of the Americans with Disabilities Act, a service animal is a dog or miniature horse, individually trained to perform tasks related to the person’s disability.
If yes, what tasks has the animal been trained to do for you?
   
Describe your pet's training issue:  
Has the animal been seen by a behaviorist/trainer? Yes    No
Name of Trainer
Address of Trainer
Phone Number of Trainer
Date of Assessment
Estimated cost of training
Successful training is contingent on your commitment to your trainer’s recommendations, practice, and follow-through. We will contact your trainer for periodic updates. If you do not attend training sessions or follow through with recommendations, you will be required to repay training costs.
PLEASE UPLOAD TRAINER DOCUMENTATION HERE:

OR EMAIL TRAINER DOCUMENTATION TO services@harleys-hopefoundation.org

   
Species and number of other pets in the household:
Are all other pets spayed or neutered? Yes    No
If “No” and the animal is over one year old, you do not qualify. Do not proceed with the application. The only exception to this policy is if your veterinarian provides documentation that the animal has a medical condition that makes spaying/neuter a high risk procedure.
Are cats kept indoors? Yes    No
If no, please explain
Are dogs kept outside? Yes    No
If yes, please explain
Are dogs kept chained? Yes    No
If yes, please explain
Do dogs ride in the back of trucks? Yes    No
If yes, please explain
Name of Veterinarian/Veterinary Clinic
Address of Veterinarian/Veterinary Clinic
Phone Number of Veterinarian/Veterinary Clinic

 

HARLEY’S HOPE REQUIRES ALL FUNDING RECIPIENTS TO:

1.  Grant permission to use your photo and your animal’s photo and story in marketing and fundraising materials.
2.  Consider a future monetary donation when your financial situation improves.
3.  Consent to follow-up phone calls/emails from a HHF representative within 2 weeks, 6 months and 1 year post-assistance. If HHF does not hear back after two attempts to contact you, you will not be eligible for any future assistance from Harley’s Hope Foundation.
4.  Inform HFF if your address or phone number changes during the 12 month post-assistance period.
5.  View educational pet care workshops offered through HHF’s annual HOPE Series available on YouTube or HHF website.

Do you agree to all requirements?     
Yes    No

Check here if you certify below:

I certify that the answers on this application form are true and correct, and understand if I willingly provide false answers, Harley's Hope Foundation will take legal action to recoup the funding obtained under fraudulent means. Furthermore, I agree to release Harley’s Hope Foundation and its service providers (veterinarians, trainers, and fosters) from liability should the veterinary care, emergency foster care, or behavioral training rendered prove unsuccessful or the animal becomes ill or injured while in our care.

 

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