Please complete the following information regarding you and your pet: Tell Us About YourselfName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Cell PhoneEmail* Active: Duty or VeteranMilitary Branch*Rank (Please note if retired)*BaseHow did you hear about the HP Program?*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 at this time*Tell us about your military service:*Tell Us About Your PetPet's Name*Age*Breed*Color*Pet's Sex*MaleFemaleWeight*Are you able to pledge a recurring donation each month to Helping Paws? If so, how much?*Click here to make your pledgeI declare that I have exhausted all alternative options to me for financial assistance and I agree to (initial next to agreed upon term):I agree to reimburse Helping Paws for any funds received upon a change in my financial circumstances.*I agree to volunteer for Helping Paws’ special events and fundraisers.*I authorize Helping Paws to use my and/or my pet’s photograph, video and any information relating to his or her procedure and outcome. This is required for fundraising purposes. Please notify us if you are unable to agree to this.*Which hospital location do you prefer to visit? Carlsbad, Escondido or Vista. Which hospital location do you prefer to visit?*CarlsbadEscondidoVistaI hereby contest that: - I do not own or operate any form of for-profit breeding or pet shop. - I understand that these funds are to be used at a participating Helping Paws veterinary hospital. - I understand that Helping Paws is not responsible for the treatment and/or outcome of any veterinary services provided and hereby waive all claims of liability against the Helping Paws charitable fund. - I understand that Helping Paws reserves the right to deny a request for financial assistance to anyone for any reason. - I declare, under perjury, that the foregoing is true and correct to the best of my knowledge.Full Name as SignatureDate VerificationCAPTCHA To expedite your need, we encourage you to apply for Care Credit and forward their response to us at email@example.com. Thank you.