Help Request Form - Helping Paws Foundation

"*" indicates required fields

Tell Us About Yourself

Your Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Email*

If you are a Veteran, has the U.S. Department of Veterans Affairs (VA) issued you a disability rating?*

Yes

Does Not Apply

What is your combined VA disability rating?

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Active Duty or Veteran & list your Rank (note if retired)*

Military Branch & Base*

How did you hear about us (if it's a veterinary clinic, specify which one)?*

Please provide a detailed description of what's wrong with your pet and what your concerns are*

Explain why you are unable to cover the costs for your pet.*

Tell us about your military service (i.e. years served, any deployments or achievements):*

We realize the following information is sensitive. Please know some grant applications ask for this information so they can better understand the people we serve when deciding whether or not to donate to the Helping Paws Foundation. Thank you for filling these in and helping us help you.

Age*

18 to 30

31 to 50

51 to 64

65+

Ethnicity*

White

Asian

American Indian

Black or African American

Middle Eastern or North African

Hispanic Latino or Spanish origin

Native Hawaiian or Other Pacific Islander

Other

Gender*

Woman

Man

Non-binary

Prefer to self-describe

Prefer not to say

Marital Status*

Married

Single

Divorced

Widowed

Prefer to self-describe as:

Household Income*

$0 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 or more

Education*

Some High School

High School

Associate’s Degree

Bachelor’s Degree

Master’s Degree

Ph.D. or higher

Tell Us About Your Pet

Pet's Name*

Age*

Breed*

Pet's Gender*

Male

Female

Weight*

Upload Military ID

If possible, please upload a photo of your military ID, such as a Common Access Card (CAC), a Uniformed Services ID (USID) or a Veteran Health Identification Card (HVIC). If your card has been lost or stolen, please look for a piece of mail addressed to you from an official military-related organization, such as the Veterans Administration.

Drop files here or

Max. file size: 128 MB.

Upload a current photo of your pet*

Drop files here or

Max. file size: 128 MB.

Upload a photo of you/your family, and your pet in need (if possible, please include one of you in uniform with him/her)*

Drop files here or

Max. file size: 128 MB.

I hereby confirm that:

I promise I have exhausted all options for financial assistance available to me. If my financial circumstances were to change for the better during this process, I agree to reimburse the Helping Paws Foundation for any veterinary services they paid.*

I agree to fill out a testimonial after my pet is treated and allow the Helping Paws Foundation to use the photos I have uploaded, as well as the treatment and outcome of my pet for marketing and social media purposes. I understand this helps with fundraising as well. (If you are unable to agree to this, please let us know).*

I understand my pet’s treatment will be at one of the three Mohnacky Animal Hospitals and I waive all claims of liability against the Helping Paws Foundation and/or the Mohnacky Animal Hospitals regarding the treatment and/or outcome of any veterinary services provided.*

I do not own or operate any form of for-profit breeding farm or pet shop.*

I do not own or operate any form of for-profit breeding farm or pet shop.

I understand the Helping Paws Foundation reserves the right to deny a request for financial assistance to anyone for any reason.*

I understand the Helping Paws Foundation reserves the right to deny a request for financial assistance to anyone for any reason.

I declare under perjury, the foregoing is true and correct to the best of my knowledge.*

I declare under perjury, the foregoing is true and correct to the best of my knowledge.

Once you hit submit, read the confirmation page for instructions; check your spam file if you don’t receive an email from us.

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