Hand In Paw November Learning Series Financial Assistance Request

Applications must be submitted by November 3rd, 2020. Since our programs sell out very quickly we recommend that you return the scholarship application as soon as possible. Spaces are limited and will be filled on a first come first served basis.

Please contact ikoopmanleyva@hssaz.org (520.327.6088 ext 142) 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.

Please be aware that the Humane Society of Southern Arizona will only grant one scholarship per household.

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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 the box for the session for which you are requesting a scholarship. One session per family only.

Hand In Paw November Learning Series (online)
November 7, 14 & 28, 2020

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* 3. Please check all that apply:
If proof is not provided by November 3rd, 2020, applications will not be considered.

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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* 4. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above, but MUST be submitted by November 3, 2020 or the application will not be considered.

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

Choose File

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

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* 6. Please select the type of scholarship you are applying for.

Partial scholarship in increments of 25%, 50%, or 75%. Remaining balance must be paid by December 18, 2020

Full Scholarship

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* 7. 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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* 8. 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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* 9. 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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* 10. Please list any person(s) who MAY NOT have contact with this child.

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

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

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

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

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

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

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

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* 18. Hospital Preference

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* 19. Photo Release: I hereby authorize the Humane Society of Southern Arizona, Inc., to photograph and use my child'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.

I authorize photo release

I decline photo release

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* 20. Liability and Assumption of Risk: Humane Society of Southern Arizona programs are a public service and we are unable to accept liability in the case of an accident. It is necessary to have your consent and agreement prior to program participation, that the sponsoring organization and personnel will not be held liable in case of accident or illness. I hereby give my permission for myself and/or my child to participate in all HSSA program activities. The HSSA, HSSA employees, and HSSA volunteers will not be held responsible in case of accident, mishap, or illness. 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

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* 21. I, the responsible party, acknowledge and represent that I have read the terms above, understand its terms and conditions, and agree to be bound by those terms and conditions without limitation or exception.

I agree

I disagree

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* 22. HSSA works closely with the Arizona Department of Corrections (ADOC). ADOC selected inmates work on the HSSA Main Campus daily and will be present in areas were student participants tour, care for foster animals and on the HSSA campus during the time of our programs. HSSA Education staff will be supervising child participants at all times and will never under any circumstances be left unattended with inmates. Additionally, the ADOC has designated staff to supervise all inmates, as well as hourly corrections officer visits to account for inmates. HSSA relies on the services the ADOC program offers. Inmates care for, train, groom and feed our shelter pets and maintain the HSSA property. This program reduces recidivism rates and is also a learned skill that inmates may then retain and use once reinstated back into our community. Should you have any questions or concerns about the ADOC program, please contact the Director of Education and Outreach. I understand inmates are present on the HSSA campus during the times when my child will be attending camps.

Agree

Hand In Paw November Learning Series Financial Assistance Request

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* 1. Please provide the following information

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* 2. Please check the box for the session for which you are requesting a scholarship. One session per family only.

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* 3. Please check all that apply:If proof is not provided by November 3rd, 2020, applications will not be considered.

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* 4. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above, but MUST be submitted by November 3, 2020 or the application will not be considered.

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

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* 6. Please select the type of scholarship you are applying for.

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* 7. Please review and acknowledge the following statement:

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* 8. 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

* 9. 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

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

Question Title

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

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

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

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

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

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

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

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* 18. Hospital Preference

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* 21. I, the responsible party, acknowledge and represent that I have read the terms above, understand its terms and conditions, and agree to be bound by those terms and conditions without limitation or exception.

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* 3. Please check all that apply:
If proof is not provided by November 3rd, 2020, applications will not be considered.