Application for Assistance

Application for Assistance

Apply for assistance through Harley's Hope Foundation. Please complete all required sections and upload requested documents.
Applicant Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Street Address

Street Address

Street Address Line 2
CityStateZip Code
County (must be located in Colorado)
How did you hear about Harley's Hope Foundation?
Are you 50 years of age or older?
Have you had your pet in your home more than 6 weeks?
We are sorry, but you do not meet our program guidelines. Please visit our resources page for a listing of other veterinary assistance programs.

Details of Assistance Requested
Describe the medical issue or reason for assistance
Do you have a diagnosis, survival prognosis, and estimate for treatment?

No (please explain)
Please list any/all of your pet's underlying health issues, even those that are not related to your current issue.
Note that underlying health issues will not necessarily eliminate you from consideration. However, if you fail to list your pet's health issues, and those issues negatively impact your pet's outcome, HHF will reserve the right to take legal action to recoup any grant funds paid out on your case. If there are no underlying health issues, enter "None" in the block.
Assistance Start Date

MonthDayYear
Assistance End Date (if known)

MonthDayYear
List any other pets requiring assistance (name, species, breed, age, spayed/neutered, vaccinated)
List size of pet(s) and type of food being requested for each pet (type of animal, wet or dry food, preferred brand)
Are you requesting any additional pet supplies (e.g. cat litter)?

Yes (please describe)
When is transportation needed?

MonthDayYear
Pick-up address
Destination address
Type of pet(s) being transported
Estimated cost of care (if known)
Upload veterinary estimate or invoice (if available)

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Are you able to contribute to the cost of care?

Yes (list how much you can contribute)
List all other charities you have applied to for assistance and the amount received, if any.

Financial Information
Number of adults in household
Number of children in household
Total monthly household income (before taxes)
Source of income

Other
Have you applied for assistance from Harley's Hope Foundation before?
If yes, when did you apply and for what service?
Upload proof of income (pay stub, benefits letter, etc.)

Please make sure to redact any sensitive information. If you are unable to upload the documents, please email to petcare@harleys-hopefoundation.org.
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Terms and Conditions
Signature of pet's legal owner
Should be Empty:

We are sorry, but you do not meet our program guidelines. Please visit our resources page for a listing of other veterinary assistance programs.