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* ActiveMilitary BranchVeteranMilitary BranchRank (Please note if retired)BaseHow did you hear about the HP Program?*What is your need?*Tell us about your military service:*Tell Us About Your PetPet's Name*Age*Breed*Color*Pet's Sex*MaleFemaleWeight*Dog Vaccine History DHPP (Distemper 4 or 5 in one) Bordetella (Kennel cough) Rabies 1yr Rabies 3yr Other DHPP (Distemper 4 or 5 in one) Date administered:Bordetella (Kennel cough) Date administered:Rabies 1yr Date administered:Rabies 3yr Date administered:Other Vaccination Date administered:Cat Vaccine History FVRCP (Distemper 5 in one) Feline Leukemia Rabies 1yr Rabies 3yr Other FVRCP (Distemper 5 in one) Date administered:Feline Leukemia Date administered:Rabies 1yr Date administered:Rabies 3yr Date administered:Other Vaccination Date administered:Are you able to pledge a recurring donation each month to Helping Paws? If so, how much?*I 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.*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.