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

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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.)
•  Veterinary notes with diagnosis.
•  Veterinary notes with prognosis. Prognosis must be fair or better.
•  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/vetassistanceapplication.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
Do you have an established relationship with a veterinary clinic?
All eligible clients must have a veterinarian who will confirm that their animals do receive routine preventative care to show proof of responsible pet guardianship.
     
• Is this a major or emergency situation?
HHF does not fund preventative care.
     
• Do you have a diagnosis, prognosis for survival, and estimate?
All applications must be accompanied by the veterinary professional providing this information. HHF does not pay for diagnostic tests and only animals with a fair to good prognosis for survival will be considered.
     
• Are you able to secure additional funding up and above what HHF offers?
HHF caps its assistance at $500 per animal. Payment is made directly to the service provider. If the estimate for treatment exceeds $500, applicant must secure additional funding before HHF will make payment.

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 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 veterinary care? Yes    No
If yes, why can't/won't they help?
Have you or will you consider selling belongings to pay for veterinary care? 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
Care Credit



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 medical issue:  
Has the animal been seen by a veterinarian? Yes    No
Name of Veterinarian/Veterinary Clinic
Address of Veterinarian/Veterinary Clinic
Phone Number of Veterinarian/Veterinary Clinic
Date of last exam
Estimated cost of treatment
PLEASE UPLOAD VETERINARIAN DOCUMENTATION HERE:

OR EMAIL VETERINARIAN 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
If your pet's injury was caused by unsafe or unsecured home environment, are you willing to correct the condition? Yes    No
If not, please explain
Some things you can do:
  • Keep debris, sharp objects, toxic substances, pesticides out of yard
  • Cover electrical cords
  • Anchor heavy objects to wall
  • Secure fenced area so your pets are not allowed to roam free
Do you provide your pets with regular veterinary care? Yes    No
If no, please explain why not:
When is the last time your pet was seen by a veterinarian for a full wellness exam?
(If your pet has gone more than 18 months without seeing a veterinarian, you do not qualify. Please do not complete the application.) This is equivalent to 10 years without seeing a human doctor.
Name of Veterinarian/Veterinary Clinic
Address of Veterinarian/Veterinary Clinic
Phone Number of Veterinarian/Veterinary Clinic
(Applicants must have an established relationship with a veterinarian in order to qualify for assistance. Please note we may contact your veterinarian to confirm that they have treated your animal. If you have recently moved and have not yet found a veterinarian in your new location, please list your most recent veterinarian.)
In the case of veterinary treatment/surgery, are you capable of and willing to continue caring for this animal? Yes    No
Please explain how will you will finance this continuing care if you cannot afford to pay for emergency/major treatment?
If you are applying for help with a chronic (ongoing) health condition, what is your plan for paying for ongoing care for your pet? Continued application to charities is not an acceptable answer as most charities will not support any one animal in need.
Please note that additional veterinary expenses can occur post-treatment that are not covered by HHF. These expenses may include follow-up care with your regular veterinarian, oxygen treatment, surgery, and rehabilitation. Are you prepared and willing to follow-through with the full prescribed course of treatment, and agree not to euthanize your pet once treatment has begun except on the advice of the attending veterinarian? Yes    No
If you are not able to care for your pet, are you willing to surrender said pet to another party that can provide care, including a legitimate, limited admission animal rescue? Yes    No

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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