ABOUT YOU

First Name: Last Name:
Your Date of Birth: Day: Month: Year:
Street Address:
City: State: Zip:
Home Phone: Work Phone: Extension:
Email Address:
How many children live in your primary residence?
How many adults (including yourself) live in your primary residence?

ABOUT YOUR PET

Pet's Name: Pet's Age: Pet's Sex: Male Female
Pet's Breed:
Is this animal a show dog, breeding dog or fight dog? Yes No
Are you the owner of this animal? Yes No
How long have you owned your pet? Years Months
How many other dogs and/or cats do you own?
Do you breed any of your dogs or cats? Yes No
Is your pet current on all vaccinations? Yes No
Is your pet spayed or neutered? Yes No
Is the pet's injury/illness life-threatening, and are you being forced to consider euthanasia or surrender as a result of the cost of treatment? Yes No
When did the injury/illness first occur?
What is the specific treatment needed?
What is the urgency of the treatment?
What is the prognosis should your pet receive this treatment?
What is the estimated cost of the proposed treatment? $
What medical testing and/or treatment has your pet already received?

ABOUT YOUR VETERINARIAN & VETERINARY CLINIC

Name of Treating Veterinary Clinic:
Name of Treating Veterinarian:
Clinic Street Address:
City: State: Zip:
Clinic Phone:
Clinic Email Address:

ABOUT YOUR EMPLOYMENT

Are you currently unemployed? Yes No    (If the answer is no, please skip the next two questions.)
If yes, how long have you been unemployed?
If yes, who was your previous employer?
What is your total annual household income? $
Name of Employer:
What is your job title?

OTHER INFO

If your application is based on temporary financial hardship (sudden job loss, major illness in the family, divorce, etc.) please give a brief description:
Have you previously applied for and/or received a Buddy Care Grant? Yes No
If so, when?
Have you ever been charged with animal cruelty? Yes No
How did you hear about us?

If approved for a Buddy Care Grant, do we have permission to use your name and story, and all submitted photos for promotional and fundraising purposes? Yes No

Should your financial situation change in the future, are you willing to consider sponsoring the treatment of another canine companion through the Buddy Care Foundation? Yes No

Is there any other information your would like us to know?


I have read the eligibility requirements. Yes No

II certify that the answers given herein are true and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying documents) will be cause for immediate denial. Yes No