Medical Assistance
Behavior Modification
Rx Food
Rx Meds
Donate
Giving Hope Application
This application is to a request for assistance for families living in Erie or Crawford counties in PA. This is NOT for animal surrenders!
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Indicates required field
Is this a medical emergency? (Life or Death situation)
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Yes
No
Maybe
Currently at Vet or ER with pet
Name
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First
Last
Street Address
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State
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Zip Code
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County
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Email
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Phone Number
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Do you text?
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Yes
No
You must answer every question for the submit button to send the application. Please use N/A for questions that do not require an answer from you.
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I understand
Every application, need and dollar amount requested, is considered but not guaranteed.
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I understand
Have you or anyone in your household ever been convicted of animal cruelty or neglect?
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Yes
No
List ALL adults living in the home. MUST include Full name & Birthdate
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MUST include Full name & Birthdate
List ALL animals in the home: include species, sex & age (include those that do not need our help)
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Are all animals current on Rabies Vaccination?
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Yes
No
If not, which animal(s) is not current on Rabies Vaccination?
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If none please enter N/A
Can you provide animal veterinarian vaccination records for each pet?
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Yes
No
Are ALL the above animals spayed or neutered?
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Yes
No
Scheduled
If not, who is still intact?
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List pets name that is not spayed or neutered. Please explain medical reason if the animal can not be altered.
We require all animals in the home to be spayed or neutered. Are you willing to have your pets spayed/neutered?
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Yes
No
Medical Reason surgery can not be done
Can not afford
Do you breed your animals?
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Yes
No
Do you have any animals that live outside excluding farm/herd animals?
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No
Dogs
Outside barn cats that ARE spayed and neutered
Outside barn cats that are NOT spayed or neutered
Other
What is your veterinarians name & phone number?
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What is used for confinement while your pet is outside?
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FULLY enclosed fenced yard
Chain/Cable
Zip line/ Dog runner
Wireless Fence/Inground Fence
Leash in hand
Dog kennel
Other
None, my dog doesn't leave yard
None, my dog doesn't have outside time
How do your household animals get daily exercise?
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We do NOT provide services/assistance to families that purchase/adopt/take-in new animals while receiving help. This program is provided to help you care for your current animals. Do you fully understand and agree to NOT add any additional animals into your custody until you are able to properly care for your current animals.
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I understand
What type of assistance do need you help with?
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Do you legally own the animal that you are requesting help for? If not, please stop the application and ask owner to complete.
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How long have you owned this animal?
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Giving Hope will need to fundraise for each animal we help. We do this on social media. Do you agree to allow us to share your animals needs/situation on social media for the fundraiser? This will not include your personal information.
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Do you agree to send pictures of the animal in need for the fundraiser?
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Medical
If you need assistance with an animals medical situation, what animal is in need?
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Was this an accident? If yes, please explain.
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Was this due to abuse or neglect? If yes, please explain.
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Have you tried seeking help from others? If yes, who?
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Have you applied for Care Credit?
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Yes
No
Denied
When did this condition start?
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What have you done so far?
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Do you have an existing bill or estimate of veterinarian care/procedure needed?
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Pregnancy
Was this animal intentionally bred?
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Has this animal received any veterinarian care during the pregnancy?
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Do you agree to spay this animal once babies are fully weaned and safe for the mother?
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Yes
No
Giving HOPE will need to cover expense
N/A
If Giving Hope assists with any pregnant or nursing animals, Giving Hope MUST spay or neuter the babies when age appropriate. To do this, Giving Hope MUST adopt them out ourselves. Giving Hope will provide everything needed to care for the nursing babies including their veterinarian care. Babies must stay with their nursing moms until appropriate weaning age. By accepting our assistance, do you understand that you are to surrender the babies?
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Yes
No
N/A
Medication
Is this medication prescribed by your veterinarian?
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What medical condition is this medication helping to treat?
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Is this medication lifelong?
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Have you used Good Rx?
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Behavior
Have you contacted a professional dog trainer? If yes, who?
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Have you had a recent veterinarian visit due to change in behavior?
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What brand of food does this animal eat?
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Are you open to make changes within the household to manage behaviors?
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Are you open to working with a professional dog trainer to modify behavior?
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If we provide the trainer are you willing and fully committed to work with your dog to help them overcome behaviors?
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Food
Do you need help with a prescription food prescribed by your veterinarian?
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Other needs
Please explain in detail how we can provide assistance?
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Additional information to help us understand your need and situation.
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I understand that purposeful falsification of the information contained in this form will result in automatic denial to receive any assistance from the Giving Hope Program. I certify that the information I have provided herein is accurate and I authorize Giving Hope to investigate all statements made on this questionnaire. I understand that Giving Hope makes no representation or guarantee that I will receive any assistance through the Giving Hope Program. Giving Hope will not be held liable for any future illness, injury, damage or death of your animal. All decisions made on behalf of your animal are made by you, the owner. Owner is responsible for any final decisions made and their outcomes. Giving Hope reserves the right, at our sole discretion, to refuse any applicant for any reason. Typing in your name below is your signature that you fully understand and agree with this paragraph.
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Submit
Medical Assistance
Behavior Modification
Rx Food
Rx Meds
Donate
