Rochester Hope for Pets Application for Financial Assistance
If you need help completing this form, please call 585-271-2733 x189, or email rochesterhopeforpets@gmail.com.
Email address *
Applicant Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Number of Adults in Household *
Your answer
Number of Children in Household *
Your answer
Number of Pets in Household *
Your answer
Total Family Income *
Your answer
Please indicate if you are a recipient of any of the following: *
Required
Pet Name *
Your answer
Pet Species *
Breed *
Your answer
Age *
Your answer
Sex *
Spayed/Neutered? *
Date of Last Rabies Vaccine
MM
/
DD
/
YYYY
Do you own the animal? *
How and when did you acquire the animal? *
Your answer
Which veterinarian does your pet regularly see? If none, leave blank.
Your answer
Type of Service Required *
Please describe the nature of care your pet requires and any qualifying life event that has affected your ability to cover the full cost of care. *
Your answer
Please send an estimate from your veterinarian regarding the cost of your pet’s care. This is required for your application to be considered. You may email, fax, or mail it. *
Total Anticipated Fee *
Your answer
From which veterinary hospital did you obtain the estimate? *
Your answer
By submitting this application, I attest that I have accurately completed this application and understand Rochester Hope for Pets has the right to accept or reject this application without recourse or reason. I understand that funds may not be available at the time of application. I also understand that I will be contacted if an award is to be granted. I further certify that the information given above is true.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service