VAP EMERGENCY FUND APPLICATION

APPLICANT INFORMATION (Pet Owner must complete)

Name

First NameLast Name

Street Address

City

State

Zip Code

Home Phone #

Alternate Phone #

Email Address

example@example.com

Qualifications (check all that apply)

I am over 65 and on financial assistance.I am over 55, disabled and on financial assistanceI am a United States Military Veteran

Please list the type of assistance you are receiving

Pet's Name

CatDog

Pet's Name

Breed

Mixed Breed?

YesNo

Age

Color

Weight

Gender

MaleFemale

Date when was diagnosis made

Date

Diagnosis

Veterinarian name and location

What will happen if the the pet is not treated?

Has this animal received vaccinations?

YesNo

Date Last vaccinated

Date

Has this animal been spayed or neutered?

YesNo

Acknowledgement (Pet Owner and veterinarian must sign)

I hereby certify that the information provided in this application is true and correct to the best of my knowledge. If approved, funds will be paid directly to the Veterinarian.

Applicant's signature

Date

Veterinarian's signature

Date

Approved or Denied

Reason for Denial

Date Check Issued

Date

Check #

Amount

Check Issued to

Below are general guidelines and the process to submit an application for emergency funds. Every request will be reviewed on a case by case basis. Assistance is limited to $150 per application and $300 annual per owner. VAP's Emergency Fund reserves the right to either grant or deny a funding assistance request without further explanation. In addition, final funding decisions will be based on resources available. Payment will be paid directly to the veterinarian.

1) The owner must be over 65 and on financial assistance or

2) The owner must be disabled and over 55 and on financial assistance or

3) The owner is a United States Military Veteran

4) The owner has exhausted their own resources

5) The cat or dog must have a treatable condition that requires medication

6) The veterinarian's prognosis (in the veterinarian's best professional judgment) indicates that euthanizing the cat or dog is required to avoid further suffering.

7)The owner consents to allow Valley Animal Partners to use any pictures and descriptions of medical care for the purposes of promotion and fund raising.

The following will not be funded:

1) Medical care for pets with a poor prognosis or already deceased.

2) Medical bills already covered by other resources.

3) Cancer diagnosis or treatments.

4) Spay/Neuter or routine medical care or vaccinations.

1) The pet owner must complete the "Applicant Information' section of the application.

2) The pet owner must sign the "Acknowledgement' section of the application.

3) The veterinarian must complete the 'Pet Information' section of the application.

4) The veterinarian must sign the "Acknowledgement' section of the application.

5) The veterinarian can submit the application to Valley Animal Partners (VAP):

a. Mail application to: VAP Emergency Fund for Snoqualmie Valley Cats and Dogs

303 Sydney Avenue N, North Bend , WA 98045

b. Email application to: ValleyAnimalPartners@gmail.com

c. Who to contact if you have need an immediate response:

i. Andrea Logan: 425-466-4621 or alogan30@comcast.net

i. Andrea Logan

ii. Carolyn Loew: 425-295-1262 or c.l.loew@comcast.net