LHS CPR Application

Crisis Pet Retention Fund Application

We understand that hardships happen. If you are a Douglas County resident and your pet family is struggling with basic pet care, access to veterinary care, or access to pet-friendly housing, we may be able to help. Our Crisis Pet Retention (CPR) Fund's primary focus is to keep pet families together. Upon submitting a complete application, it may take up to 5 business days for review.
- If at any point you need to leave this form quickly, please utilize this Exit Form link.
- You can save your progress by scrolling to the bottom of the form, under the Agreement & Acknowledgment section.

Financial Contribution Information
The Crisis Pet Retention Fund is made possible through the generous donations of our supporters and the partial payment and repayment of supportive services by fund recipients. This model allows us to continue helping other pet families in need, ensuring we can provide vital assistance during times of crisis.

As part of this application, we ask that you consider a payment and repayment option that works best for your current financial situation. Repayments are not mandatory, but they help sustain the program for other families facing emergencies and ensure we can continue to help other pets and people in Douglas County.

Your selection will not affect your eligibility for assistance, and all information shared is kept confidential. Thank you for being part of a program that supports pets and their families in times of need.
Please select the payment and re-payment option(s) you are most interested in. Select all that apply.*

Partial payment at time of services requestedFull repayment in one installmentRepayment in monthly installments over 3 monthsRepayment in monthly installments over 6 monthsRepayment in flexible, interest-free installments as your situation allowsUnable to commit to payment OR repayment at this timeOther

Agreement & Acknowledgment
By submitting this application, I attest that it has been completed in good faith. I understand that incomplete applications and/or the submission of false information may result in my application being denied. By signing below, I attest that I am the lawful owner and/or a representative lawfully authorized to make decisions on behalf of the animal(s) described in this application.*

I agree
I understand that by submitting this application I am only requesting assistance from the Lawrence Humane Society and that assistance is not guaranteed.*

I agree
If approved for assistance, I authorize the Lawrence Humane Society to share information about my participation in the Crisis Pet Retention (CPR) Program with donors and grantors.*

I agree
I grant the Lawrence Humane Society and its agents to the unrestricted right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all photographs and/or video taken of me or my family to be used for any promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications. I hereby release the Lawrence Humane Society, its directors, officers and employees, and any third parties involved in the creation or publication of the photographs and/or video images of me or my family from liability of any claims by me or any third party in connection with my participation.*

I request that my name and other personal identifying information not be shared.I agree to allow my first name and other personal identifying information, including photos and/or videos to be shared.
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Crisis Pet Retention Fund Application

Client/Pet Owner Information

Demographic & Household Information

Support & Assistance Request information

Other Information