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Boydston Grant
SCVMA and Animal Health Foundation Boydston Grant Owner/Pet Application Form
Please fill out this page completely for consideration for Boydston Grant eligibility. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
APPLICATION REQUIREMENTS
This application needs to be completed and submitted once.
By filling out the information below, this hospital agrees to the following:
*Our hospital has at least one current SCVMA member veterinarian
*We agree to share information about the case and the client including a high resolution photograph of the pet and owner
*We agree to screen the client for needs and age PRIOR to submitting the application
*We understand there is a limited amount of funding and we are only eligible for $1000.00 per year.
*We understand that any activity that might be considered fraudulent will be reported to the appropriate authorities.
*We understand NOT everybody in need can be assisted.
*We agree to help further the AHF-SCVMA Boydston Grant by placing a collection jar in our lobby if asked to do so.
*We agree that our practice name and doctor's names maybe used in Press Releases created to promote the Boydston Grant, Animal Health Foundation, and SCVMA
1.
PART A: TO BE COMPLETED BY OWNER
Pet Owner's Name
Pet Owner's Phone Number
Pet Owner's Email Address
Pet's Name
Pet's Breed
Pet's Sex
Is the pet spayed/neutered?
Pet's Age
Owner’s reason for applying for Angel Fund:
As the owner of this pet in need, I agree to: 1) Discuss my financial needs with the hospital and provide personal information regarding this case. 2) Provide a picture of my pet and information about myself and this case for press releases. 3) Contribute at least 10% of the cost of the case.
*
2.
I certify that all of the above have been answered truthfully and accurately.
(Required.)
Owner's Name/signature
Date
3.
Part B: TO BE COMPLETED BY VETERINARY HOSPITAL REPRESENTATIVE
Hospital Name:
Veterinarian/Manager’s Name:
Dollar amount requested by the hospital:
Summary of the treatment needed for this pet, include dates of treatment.
4.
To the best of my knowledge, the information below is TRUE (DVM/Manager initial in box):
Owner has proven to be older than 65 years of age
Owner has no Credit Cards available:
Owner has no Checking Account funds available:
Owner is not eligible for Care Credit (or similar):
Owner will contribute 10% or more of the total bill:
Pet is spayed/neutered, or will be before discharge (at the owner’s expense):
Copy of the Estimate (signed by owner) has been emailed to membershipdesk@scvma.org or faxed to (714) 821-7213
This request is within TWO WEEKS of the procedure/treatment:
5.
I certify that all of the above have been answered truthfully and accurately.
Hospital Director/SCVMA Veterinarian/Representative
Date
