Rochester Hope for Pets Application for Financial Assistance
If you need help completing this form, please call 585-537-5400, or email info@rochesterhopeforpets.org.
Email address *
Applicant Name *
Phone Number *
Address *
City *
Zip Code *
Number of Adults in Household *
Number of Children in Household *
Number of Pets in Household *
Total Family Income (per year) *
Applicant's Age (in years) *
Please indicate if you are a recipient of any of the following: *
Required
Pet Name *
Pet Species *
Pet's Breed *
Pet's Age (in months or years) *
Pet's Sex *
Spayed/Neutered? *
Do you own the animal? *
How and when did you acquire the animal? *
Which veterinarian does your pet regularly see? If none, leave blank.
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. *
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 *
From which veterinary hospital did you obtain the estimate? *
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.
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