| Name: |
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| Email address: |
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| Street address: |
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| City, State, Zip: |
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| Two phone numbers: |
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| Additional contact person: |
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| Name of Rescue Dog: |
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| Gender of dog: |
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| Neutered? |
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| Dog's approximate age: |
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| Has the dog's breeder (if known) been contacted? |
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| Where did you get this rescue dog (i.e. shelter, private owner, stray)? |
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| Why was this dog given to rescue? |
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| How long have you had this dog in rescue? |
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| Has this dog shown any aggressive behavior? Please explain: |
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| Do you have a foster home who will commit to keeping this dog through treatment and recovery period? If yes, who? |
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| Please provide a full description of the rescue dog's illness or injury, including diagnosis: |
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| What is the course of treatment? |
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| What is the dog's prognosis? |
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| Are there any other health concerns or issues that would make this dog a poor candidate for adoption? Please explain: |
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| Is this a life-or-death emergency? |
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| Where is the dog currently (shelter, veterinarian, boarding, foster home)? |
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| Name of Veterinarian clinic: |
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| Name of treating veterinarian: |
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| Vet's address: |
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| City, State, Zip: |
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| Vet's phone number: |
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| Fax Number: |
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| Is this your regular rescue vet? |
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| How long have you used them? |
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| Will they give a rescue discount? |
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| Estimated cost of treatment: |
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| How much will your rescue group be able to donate towards this treatment? |
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| Are there any fund-raisers being done to help this dog? Please explain: |
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| How did you find out about SamUrgency? |
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| Have you applied for funds from SamUrgency before? If so, when? |
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If funding is approved I agree to abide by all rules and contingencies set forth by the SamUrgency board.
I understand that the SamUrgency board reviews this and all applications on a case-by-case basis, but funding comes from donators who will decide which dogs to donate to. I understand that if SamUrgency decides to approve this application, they can not guarantee that their generous donators will be able to totally pay for this dog's medical bills.
I understand that SamUrgency is a funding set up to help in emergency situations and can not pay for normal rescue expenses, such as neutering, vaccinations, grooming, long-term boarding or transportations costs.
All Samoyed rescue groups qualify for SamUrgency funds. However, if you have access to other funding options such as through the National Samoyed Rescue organization, we request that you apply with them first. If additional funds are necessary, then we invite you to apply to SamUrgency to help defray the difference.
Check the following box to agree to these terms: |
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I Agree |
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