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A Fighting Chance Foundation - 2023 Grant Request Application

1.What is your name, address, phone number and email address?
2.What is your pet's name and age (estimate age if unknown)?
3.What is your pet's species, breed and gender?
4.Is your pet spayed or neutered?
5.Provide a brief explanation of pet’s medical emergency (please include required veterinary diagnosis, prognosis and cost estimate with application if you have it).
6.Do you meet A Fighting Chance Foundation’s financial eligibility requirement, applicant’s household income must not greatly exceed current Federal WIC eligibility guidelines?
7.What is your total household gross income per month (total monthly earnings; please include total financial aid, child support for all contributing members in household). Proof of income is required with your application.
8.Please specify how many adults and children live in your household. Also, do you receive social security or disability benefits?
9.By submitting this application, I attest that the information I have provided to A Fighting Chance Foundation is accurate and complete and that no one in my household, including myself, has ever been convicted of violations regarding the care of animals.  I understand that A Fighting Chance Foundation assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services.  I consent to A Fighting Chance Foundation's use of any pictures provided of my pet(s) or its owner(s), as well as a description of the medical care for purposes of marketing and fundraising. I understand any documentation or pictures given to the foundation cannot be returned. Please acknowledge these terms and conditions.
10.In order to complete your application, you must also provide proof of income, veterinary documentation, including veterinarian name, address, email and phone number; recent diagnosis and fair or good prognosis (with itemized cost estimate), and at least one picture of your pet. Please acknowledge that you will provide these items.