Hand in Paw Kid's Club Scholarship Application

This application is for a one year membership to the Hand in Paw Kid's Club.

Please contact afaulk@hssaz.org (520.327.6088 ext 171) with any questions. To submit any supplemental information, please email it to the above listed email, mail to 635 W Roger Rd, Tucson AZ 85705, OR fax to 520.325.7190.

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* 1. Please provide the following information

Child's First and Last Name *

DOB *

Parent/Legal Guardian's Name *

Mailing Address *

City/Town *

State/Province *

ZIP/Postal Code *

Home Phone

Cell Phone *

Email *

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* 2. Please check all that apply:
If you are required to show documentation as listed below, your child's membership will not be processed until the appropriated documents are provided.

As the parent or legal guardian, I am currently receiving financial assistance from the government (AHCCCS/Food Stamp Program). Please submit a legible copy of your AHCCCS or Food Stamp Card.

The child is receiving services through one of Arizona's Behavioral Health Systems. Please contact the child's case worker to submit a letter, on official letterhead, to us stating that they believe this program would be beneficial for the child. Please be aware that the program you are applying for may not be psycho-educational in nature.

The child is currently in state care or custody. Please contact the child's case worker to send us a letter, on official letterhead, confirming the child is in state care/custody.

If you and your family do not qualify for one of the above circumstances, please briefly explain below why this child will benefit from this program or why you are applying for a scholarship.

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* 3. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above. Your child's membership will not be processed until this documentation is received.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 4. Please give us a brief description of your scholarship need.

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* 5. Please review and acknowledge the following statement:

I understand the completion of this application does not guarantee funding for my child. I further realize that the Humane Society of Southern Arizona has limited funding available and that I may be denied funding support. This application will remain confidential and will be kept by the Humane Society even if I do not receive funding support.

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* 6. In case of emergency, please notify (persons other than parent(s)/guardian(s) - please include first and last name, relationship to child and phone number.

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* 7. Please list all persons responsible for picking up child including parent(s)/guardian(s). (For security reasons, no child will be released to any person not listed on this sheet.)

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* 8. Please list any person(s) who MAY NOT have contact with this child.

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* 9. Please select your child's t-shirt size.

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* 10. Does your child have any existing medical conditions that we should be informed of? If yes, please explain.

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* 11. Is your child on any medication that causes side-effects our staff should know about? If yes, please explain.

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* 12. Does your child have any allergies to food, plant, animal or any other substances? If yes, please explain.

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* 13. Does your child have any mental or physical handicaps that require specific attention? If yes, please explain.

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* 14. Does your child have any dietary needs or restrictions? If yes, please explain.

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* 15. Child's Doctor / Physician including phone number

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* 16. Hospital Preference

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* 17. HSSA is an organization that serves the public and utilizes programmatic photos and video to advertise and educate our community.

I hereby authorize the Humane Society of Southern Arizona, Inc., to photograph and use my or my child or my pet's photographic image for the purpose of education, training, publicity and/or public information in the interest of providing better and safer homes for animals in my community. I understand that these images may be used in the public forum on a local, statewide or national basis. I understand that these images may be used in a variety of mediums, including but not limited to printed materials, internet websites, social media, slide presentations, videos and related media. If you have a safety concern, please contact afaulk@hssaz.org for exemption.

I authorize photo release

I decline photo release

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* 18. In exchange for my being allowed to participate in this educational program as provided through the Humane Society of Southern Arizona (“HSSA”), I waive any claim, cause of action, charge, liability, loss, cost, damage, fees (including attorneys’ fees) or expense of any nature which I may have or incur against HSSA, or against its members, directors, officers, employees or agents (“third party beneficiaries”) arising out of or in connection with my , my child’s, or my dog’s participation in the education program in which I have enrolled. Further, to the fullest extent permitted by law, I indemnify and agree to hold harmless HSSA and third party beneficiaries from and against any and all claims, causes of action, damages, losses, expenses, charges, fees (including attorneys’ fees) and liability of any nature arising out of or resulting from my participation or that of my dog in such training classes. In the event that any action or proceeding is brought or claim is made against HSSA or HSSA employees, HSSA volunteers, and HSSA Board of Directors, arising out of or in connection with my, my child’s, or my dog’s participation, I agree to resist and defend such action, claim or proceeding on behalf of HSSA or the third party beneficiaries by counsel designated by HSSA. Should an emergency arise, I give my permission for HSSA staff to render basic first aid and/or contact appropriate emergency services.

I agree

I disagree/decline

Hand in Paw Kid's Club Scholarship Application

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* 1. Please provide the following information

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* 2. Please check all that apply:If you are required to show documentation as listed below, your child's membership will not be processed until the appropriated documents are provided.

Question Title

* 3. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above. Your child's membership will not be processed until this documentation is received.

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* 4. Please give us a brief description of your scholarship need.

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* 5. Please review and acknowledge the following statement:

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* 6. In case of emergency, please notify (persons other than parent(s)/guardian(s) - please include first and last name, relationship to child and phone number.

Question Title

* 7. Please list all persons responsible for picking up child including parent(s)/guardian(s). (For security reasons, no child will be released to any person not listed on this sheet.)

Question Title

* 8. Please list any person(s) who MAY NOT have contact with this child.

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* 9. Please select your child's t-shirt size.

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* 10. Does your child have any existing medical conditions that we should be informed of? If yes, please explain.

Question Title

* 11. Is your child on any medication that causes side-effects our staff should know about? If yes, please explain.

Question Title

* 12. Does your child have any allergies to food, plant, animal or any other substances? If yes, please explain.

Question Title

* 13. Does your child have any mental or physical handicaps that require specific attention? If yes, please explain.

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* 14. Does your child have any dietary needs or restrictions? If yes, please explain.

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* 15. Child's Doctor / Physician including phone number

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* 16. Hospital Preference

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* 2. Please check all that apply:
If you are required to show documentation as listed below, your child's membership will not be processed until the appropriated documents are provided.