Instructions:  Please respond to the following questions as specifically as possible. All information must be completed in full for the application to receive consideration.  Each item marked with an * must be answered.  Incomplete applications will be returned but may be resubmitted once all information is provided. Providing the requested information will allow the SRF Board to properly investigate the need, determine the veracity of the request, and evaluate the request based on its merits.  By providing this information, you are consenting to its use in the manner described.  We value your privacy and will not disclose your information to any third party other than for verification of your request. 
NOTE:  Pay it Forward Assistance is considered a last safety net to provide help when all other possibilities have been exhausted. It is not a large fund nor is it intended to be a substitute for personal responsibility, pet insurance or other forms of public and private assistance.
Please note the following:
  • Assistance is dependent on the need and the availability of Foundation funds.
  • There is a maximum allocation of $500.00 per household for new members who joined 30 days or less from the application date.         
  • There is a maximum allocation of $3,000.00 per household for established members (more than 31 days) within a 12 month period. The lifetime maximum household allocation is $6,000.00.
Please review the Scotties Rock Foundation's "Pay it Forward" guidelines (click this link) before completing the application below.

    Scottie Information

    Owner Information

    Insurance Information

    If you have pet insurance, please state the name of the insurance company, amount of deductible, and type of coverage

    Assistance Details

    Please provide specific information about your situation and explain why you are requesting financial assistance for this dog, including what circumstance(s) occurred for you to require assistance
    Describe the type of assistance you are requesting and attach to this application copies of all estimates or costs incurred for the veterinary expenses, surgical procedures, special food, etc.
    NOTE:  Your application cannot be considered and acted upon until written estimates are received from your treating veterinarian or receipts are attached: 

    Upload estimates and/or costs documents

    Max file size: 20MB
    Max file size: 20MB
    Alternatively, the documents can be emailed to: [email protected]

    How much funding are you requesting?

    Veterinarian contact information

    Provide the name (including clinic name, if applicable), address, telephone number and email of the treating veterinarian who has knowledge of your dog's condition:
    Please include the name and contact information of at least one other Scotties Rock member that has knowledge about your situation.

    Pay it forward

    If your application is approved, please state how you intend to “Pay it Forward” to help others.

    NOTE:  In the event your insurance proceeds and/or social fundraising exceeds your needs for your situation, we ask you to consider a pay it forward donation to the Foundation up to the amount (or more if so inclined) of your assistance award.

    Affirmation and Signature

    I have reviewed and agree to the Scotties Rock Foundation's
    "Pay it Forward" Guidelines (Click this link).

    My typed signature below indicates my full understanding of the above statements, and of the accuracy of all of the information contained in this application.