Scotties Rock Foundation
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Home
Vet Care Assistance
Donate
About Us
Meet the Team
Financial Information
2023 Spring Auction
2022 Business Partners
About Scotties
Scottie Health
Pay It Forward Assistance Application
V1-17-19
Instructions
:
Please respond to the following questions as specifically as possible.
All information must be completed in full in order for the application to receive consideration. Each item marked with an *
must
be answered.
Important: Click the
pink button
at the end of the application to send it to us.
You will see this acknowledgement that your application has been submitted if it is sent properly:
"Your information has been submitted. Please now send either a Facebook PM to Penny Standley, or an email to ourscottiesrock@gmail.com to let us know that you submitted an application so we can watch for it. (At times there are problems with transmissions.) Thank you!"
Please Note the Following:
Assistance is dependent on the need and the availability of Foundation funds.
There will be a maximum allocation of $2,000 per
household
within a 12 month period.
The lifetime maximum
household
allocation is $5,000.
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 using it 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.
*
Indicates required field
Name
*
First
Last
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number (including Area Code)
*
Cell/Mobile Phone Number (including Area Code)
*
Work/Business Phone Number (including Area Code)
*
Email Address
*
Re-enter Email Address
*
Facebook Name
*
How would you prefer that we contact you? (Select one)
*
Email
Home phone
Cell/mobile phone
Facebook messenger
Are you currently a member of Scotties Rock Facebook group?
*
Yes
No
Are you currently a member of Scotties Rock Foundation Facebook group?
*
Yes
No
What is the name, age and breed of the dog in need of assistance?
*
Please provide specific information about your situation and explain why you are requesting financial assistance for vet care for this dog.
*
Describe the type of vet care assistance you are requesting. (PLEASE NOTE: Your application will not be considered until we receive copies of written estimates for the cost of anticipated vet expenses, surgical procedures, medications, special food, etc. from you or your vet. (If requesting assistance for vet bills already paid you must supply itemized, paid statements from your vet.) Copies can be uploaded using the links at the end of this application, emailed to ourscottiesrock@gmail, or sent to any SRF Board member by Facebook PM.
*
List the name of the veterinary clinic, veterinarian, and clinic telephone number of the veterinarian who has knowledge of your dog's condition and treatment needs and health history.
*
How much funding are you requesting from Scotties Rock Foundation at this time? (PIF is considered a last resort 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 include the name and contact information of at least one other Scotties Rock member that has knowledge about your situation.
*
Do you have more than one source of income (example: income from a spouse, business income, etc.)?
*
Yes
No
If you have more than one source of income please explain:
*
What other sources of financial assistance have you applied for? (Click all that apply)
*
GoFundMe
You Caring
Banfield Foundation or other grant
Discounted vet care
Other
None
What is the total amount of financial assistance you have received from these sources to date, if any?
*
Scotties Rock Foundation is based on the "Pay it Forward" philosophy; individuals who receive funding for vet care assistance from SRF are asked to, in turn, repay that kindness in the future when financially able to do so in order that other applicants may also receive help. If your application is approved, through which method(s) could you later “Pay it Forward”? (Some examples are: Make a one-time donation to SRF; set up a monthly recurring donation to SRF; post a personal testimonial on SR and SRF Facebook pages describing how SRF assisted you and your furkid(s); participate in SRF auctions; create a fundraiser event benefiting SRF on Facebook; share SRF auction information on your Facebook page; use Amazon Smile when purchasing from Amazon with SRF as your designated charity; purchase SRF logo merchandise from Zazzle or the SRF website; and so on. Creativity is encouraged! Please list options that would be a good fit for you in the box below.
*
Please describe other "Pay-It-Forward" ideas you have:
*
I affirm that all the information contained on this application is true and correct.
*
Yes
No
I affirm that I have read the Pay it Forward Guidelines and that I have exhausted all other sources of financial means for vet care expenses and require assistance.
*
Yes
No
I agree that you may contact my veterinarian.
*
Yes
No
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.
Name
*
First
Last
Date of Application
*
Upload Vet Cost Estimate - Page 1. (Click the Browse button below to attach a document, PDF or photo that documents the vet cost estimate.)
*
Max file size: 20MB
Select the desired file
Upload Vet Cost Estimate- Page 2. (Click the Browse button below to attach a document, PDF or phot that documents the vet cost estimate.)
*
Max file size: 20MB
Upload Vet Cost Estimate- Page 3. (Click the Browse button below to attach a document, PDF or phot that documents the vet cost estimate.)
*
Max file size: 20MB
How did you learn about the Scotties Rock Foundation's Pay-It-Forward Fund and program?
*
Please add any other comments or questions you may have here.
*
To successfully submit your application you MUST click the pink button below!!
Once submitted you see a brief message on the screen noting that your information was submitted.
If you do not see that message, click the button again.
Submit the Application
Home
Vet Care Assistance
Donate
About Us
Meet the Team
Financial Information
2023 Spring Auction
2022 Business Partners
About Scotties
Scottie Health