| Name: |
|
|
| Email address: |
|
|
| Street address: |
|
|
| City, State, Zip: |
|
|
| Two phone numbers: |
|
|
| Additional contact person: |
|
|
| Name of Rescue Dog: |
|
|
| Gender of dog: |
|
|
| Neutered? |
|
|
| Dog's approximate age: |
|
|
| Has the dog's breeder (if known) been contacted? |
|
|
| Where did you get this rescue dog (i.e. shelter, private owner, stray)? |
|
|
| Why was this dog given to rescue? |
|
|
| How long have you had this dog in rescue? |
|
|
| Has this dog shown any aggressive behavior? Please explain: |
|
|
| Do you have a foster home who will commit to keeping this dog through treatment and recovery period? If yes, who? |
|
|
| Please provide a full description of the rescue dog's illness or injury, including diagnosis: |
|
|
| What is the course of treatment? |
|
|
| What is the dog's prognosis? |
|
|
| Are there any other health concerns or issues that would make this dog a poor candidate for adoption? Please explain: |
|
|
| Is this a life-or-death emergency? |
|
|
| Where is the dog currently (shelter, veterinarian, boarding, foster home)? |
|
|
| Name of Veterinarian clinic: |
|
|
| Name of treating veterinarian: |
|
|
| Vet's address: |
|
|
| City, State, Zip: |
|
|
| Vet's phone number: |
|
|
| Fax Number: |
|
|
| Is this your regular rescue vet? |
|
|
| How long have you used them? |
|
|
| Will they give a rescue discount? |
|
|
| Estimated cost of treatment: |
|
|
| How much will your rescue group be able to donate towards this treatment? |
|
|
| Are there any fund-raisers being done to help this dog? Please explain: |
|
|
| How did you find out about SamUrgency? |
|
|
| Have you applied for funds from SamUrgency before? If so, when? |
|
|
|
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.
Check the following box to agree to these terms: |
|
I Agree |
|
