Rusk Veterinary Assistance Grant Application: Pet Owner Questionnaire

Rusk Veterinary Assistance Grant Application

Pet Owner Questionnaire
To be eligible, your veterinarian must apply for you. Only veterinarians who are members in good standing of the Texas Veterinary Medical Association and who practice in the state of Texas will be eligible to apply for these grants.

The pet owner questionnaire IS NOT a grant application. It is an addendum for your veterinarian's Rusk Veterinary Assistance Grant Application.

The pet owner questionnaire WILL NOT be considered for funding without your veterinarian's application.
My veterinarian has submitted a grant application on my behalf and has instructed that I complete the pet owner questionnaire.

YesNo

Rusk Veterinary Assistance Grant Application

Pet Owner Questionnaire
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Contact Number*
Please enter a valid phone number.
Pet Name:*
Are you a Texas resident?*

YesNo
Veterinarian's Name:*
Veterinarian's Clinic/Hospital Name:*
Do you have an established relationship with your veterinarian?*

YesNoOther
If you answered "other" to the above question, please explain:*
Provide a description of your animal’s overall health in addition to the diagnosis, treatment plan, and prognosis provided by your veterinarian:*
Have you applied for CareCredit or Scratch Pay?*

YesNo
Was your CareCredit or Scratch Pay application approved?*

YesNo
Do you receive any of the following services, please check all that apply:*

SNAPTexas MedicaidWICUnemployment InsuranceSocial Security Income (SSI)Housing AssistanceLiving AssistanceHealthcareFinancial burden due to extenuating circumstances
Explain your financial circumstances in detail that qualify you for grant assistance:*
Are you able to secure funding up and above what TVMF may offer, if you are approved for assistance? TVMF caps its assistance at $1,000 per case. Payment is made directly to the veterinary clinic. No one is guaranteed the maximum award, so you must be applying to other charities and attempting to raise funds yourself.*

YesNo
Please explain other ways you are securing funds for your pet's care:*
How much are you able to contribute to your pet's care described in your veterinarian's portion of the grant application?*
Describe your relationship/bond with your pet:*
Why should TVMF consider you for a grant?*
If you were approved for a grant, what would that mean to you?*
Upload an image of your pet:*

Cancelof
Has your veterinarian submitted an application on your behalf to accompany your pet owner questionnaire?

Your application is considered incomplete and will not be considered for funding by the TVMF Grants Review Committee until your veterinarian submits the corresponding application on your behalf.
By clicking the submit button, I affirm that I am signing this application electronically and acknowledge that my electronic signature holds the same legal weight as my handwritten signature. I consent to be legally bound by the terms and conditions of this application and understand that my use of a keyboard, mouse, or other device to select items, provide information, or complete this transaction constitutes my electronic signature (“E-Signature”). I further agree that no certification authority or third-party verification is required to validate my E-Signature, and the absence of such does not impact its enforceability or the binding nature of this application.I understand that this application is incomplete and will not be considered for funding by the TVMF Grants Review Committee until my veterinarian submits the corresponding application on my behalf. I have read and agree to the grant qualifications and confirm that all information provided has been submitted in good faith. I understand that incomplete applications or the submission of false information may result in denial. Additionally, I agree that the Texas Veterinary Medical Foundation (TVMF) may share my story for the purpose of demonstrating to donors how their contributions are making a meaningful difference in the lives of animals and their owners.*

Agree
Signature*

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