Emergency Veterinary Care Application

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Name of Pet Guardian*

First Last

Email*

Phone*

City*

City

State*

State

Zip Code*

ZIP Code

Gender of pet guardian*

Female

Male

Name of Pet Co-Guardian (if any)

First Last

Have we helped you before?*

Yes

What is the name of the pet we helped before?

Are you currently experiencing homelessness?*

Yes

If yes, below, select number of years and months you have been experiencing homelessness for your current situation. If you are in a VA program enter zero below.

Years*

Please enter a number from 0 to 100.

Months*

Please enter a number from 0 to 12.

If yes, what is your homeless situation?*

If other, please describe.

Name of Agency that can verify your homelessness?*

Name of specific Agency Worker who can verify your homelessness?*

IMPORTANT: Please call your social worker, doctor, shelter supervisor NOW and grant permission to release information about you to FEEDING PETS OF THE HOMELESS. Please notify your contact before submission of this application. Please note: County agencies such as SNAP Benefits are unable to verify your living situation. Please upload your Verification of Benefits statement below.

Upload your Verification of Benefits statement

Max. file size: 128 MB.

Direct phone number of Agency Worker who can verify your homelessness?*

Please note: 800 telephone numbers are not direct phone numbers unless you have the extension.

Phone number extension of Agency Worker who can verify your homelessness?

Your Social Worker's specific email address

Are you a Veteran?*

Yes

If yes, are you a participant in the HUD-VASH or another VA Housing program?

Yes

If yes, name of VA person who can verify your participation

Phone number of VA person who can verify your participation

Are you employed?*

Yes

Do you have transportation?*

Yes

Are you disabled?*

Yes

Are you over 65 years of age?*

Yes

Are you a survivor of Domestic Violence?*

Yes

Have you ever been denied outside service because you owned a pet?*

Yes

If yes, what type of service?

Financial Assistance/Government Assistance (if currently receiving any)*

None

Food Stamps/SNAP

Housing Assistance

Cash Aid

WIC

Unemployment(EDD)

Social Security Income(SSI)

Disability (SSDI)

Other

How did you hear about us?*

Internet/website

Veterinarian

211

Social Media

Flyer

Friend/Family

Social Worker

Wellness Clinic

Volunteer

Organization

Name of organization

Pet Information:

Pet Name*

Pet Type*

Dog

Cat

Other

If other, what animal is your pet?

Breed*

Color*

Age*

Sex*

Female

Male

Is your pet spayed/neutered?*

Yes

Are your pet’s vaccinations current?*

Yes

Service animal?*

Yes

When did you acquire your pet?*

Month

or your best guess

Year

How did you aquire your pet?*

What is the medical issue? What are your pet's symptoms?*

Please provide clear information about your pet’s specific symptoms. For example, “not putting weight on front right leg."

How long has your pet been having these symptoms?*

Has your pet had diagnostics completed by a veterinarian?*

Yes

If yes, provide veterinary practice name:

Include a photo of your pet

Max. file size: 128 MB.

Terms and Conditions*

I accept the Terms and Conditions

I HAVE READ THIS RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS TERMS AND CONDITIONS. By checking the “I Accept the Terms and Conditions” box and clicking the “Submit” button, you acknowledge that you have read, understand, and agree to the above.
Consent and Release of Liability
For Online Application for Emergency Veterinary Care
By submitting this application, I hereby give my consent to receive services provided by Feeding Pets of the Homeless®, including but not limited to examinations and/or medical services rendered to my pet/animal by a licensed veterinarian.
I understand and agree that by accepting services provided by Feeding Pets of the Homeless—whether directly or through veterinary hospitals, clinics, personnel, veterinarians, officers, agents, employees, volunteers, sponsors, other participants, or any person(s) acting on behalf of the organization—I release, indemnify, and hold harmless Feeding Pets of the Homeless and all associated personnel from any and all liability, claims, or damages arising out of or related to the services rendered.
I acknowledge that medical services or treatments may involve risks, including potential adverse reactions. I agree to release, indemnify, and hold harmless Feeding Pets of the Homeless from any liability, damages, or losses resulting from such reactions or from any injury, disability, death, or loss or damage to myself, my pet/animal, or my property—whether arising from negligence or otherwise—connected to services offered or rendered by Feeding Pets of the Homeless.
By accepting services offered by Feeding Pets of the Homeless, I grant permission for the organization to use photographs of me and my pet/animal in future internet and print materials, including but not limited to the Feeding Pets of the Homeless website, publications, and social media platforms.
Privacy Notice
Feeding Pets of the Homeless® respects your privacy. The personal information you provide through this application is collected solely for the purpose of evaluating and administering emergency veterinary care services for your pet/animal.

We may collect the following information: • Your name and contact information
• Information about your pet/animal
• Details related to your situation and eligibility for assistance
• Documents or photos you voluntarily provide
Your information is used only to:
• Determine eligibility for services
• Communicate with you regarding your case
• Coordinate treatment with participating veterinary hospitals
• Maintain accurate internal records for program integrity and reporting (with all personal details kept confidential)
Feeding Pets of the Homeless maintains reasonable administrative, technical, and physical safeguards to protect your information from unauthorized access or disclosure.
We do not sell, trade, or rent your personal information.
Information is shared only with: • Veterinary hospitals involved in treating your pet
• Authorized Feeding Pets of the Homeless personnel who are managing your case

You consent to receiving email and/or text messages from Feeding Pets of the Homeless or assigned veterinarian personnel. I understand that if I provide incorrect or misleading information, including but not limited to: phone numbers, email addresses, living situation, etc. my application may be declined.
You may choose not to provide certain information; however, doing so may limit our ability to determine eligibility or provide services.
If you have questions about this notice or how your information is used, please contact us at info@petsofthehomeless.org or (775) 841-7463.

Emergency Veterinary Care Application