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* 1. What is your name, complete street address (no PO Box), phone number and email address?

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* 2. What is your pet's name and age (estimate age if unknown)?

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* 3. What is your pet's species, breed and gender?

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* 4. Is your pet spayed or neutered?

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* 5. Provide a brief explanation of pet’s medical emergency (please include veterinary diagnosis, prognosis and cost estimate with application if you have it).

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* 6. Do you meet A Fighting Chance Foundation’s financial eligibility requirement, applicant’s household income must not greatly exceed current Virginia WIC eligibility guidelines?

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* 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.

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* 8. Please specify how many adults and separately how many children live in your household. Also, do you receive social security or disability benefits?

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* 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.

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* 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.

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