Equine Feed and Hay Assistance Application Form
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do your horses live at the same address
*
Yes
No
If not, please provide the Name of the facility, the facility manager's name, and the address and phone number of the horse’s location.
When is the best time to reach you?
*
What is the best way to reach you?
*
What is the total amount of income you expect your household to receive this month?
*
Number of adults:
Number of children:
Please upload the most up to date document
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In order to qualify for our free pet programs, you must be on any of the following types of government assistance: Medicare Medicaid CHIP (Children's Health Insurance Program) SNAP (Supplemental Nutrition Assistance Program) Food Stamps Housing Assistance SSI (Supplemental Security Income) Disability Severance Unemployment Pension TANF (Temporary Assistance for Needy Families)
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Please tell us in detail what type of problem or situation you are having with your horse that prompted you to reach out for help. Please include how receiving temporary assistance will help set you and your equine(s) up for success in the future:
*
Horse Information
Do you have a veterinarian?
*
Yes
No
If yes, please include their name and phone number.
If not, do you need assistance with vaccines, Coggins, and microchips?
Yes
No
Do you need castration assistance?
Yes
No
Do you need dental assistance?
Yes
No
Do you have a farrier?
*
Yes
No
If not, would you like to haul in when the HHS farrier is on site?
Yes
No
If yes, please include their name and phone number.
How did you hear about our Feed and Hay Assistance program?
*
Do you have any other animals you need assistance for?
Dog
Cat
Cattle
Goat
Sheep
Chicken
Pig
Consent
I authorize and consent to collect and share all of my records, data, and information. I understand I may have to provide documentation of my situation. I understand this is a one-time 30-day assistance for Feed and Hay. I understand that I am receiving a ration balancer and will still need to provide for my horse's specific needs. I understand that this assistance allows me to find a permanent outcome for my horse(s) if I can still no longer provide for them after the 30 days is over. I understand that I am still eligible to pick up feed at any pet pantry event HHS hosts.
Signature
*
Submit
Submit
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