Application for Services

Application for Services
Name & Relationship of Applicant (Relative, Educator, Doctor, Friend, Etc.)*
Phone Number of Applicant*

Area CodePhone Number
Email Address of Applicant*
example@example.com
Name of Individual Needing Services*

First NameLast Name
Date of Injury*

MonthDayYear
Date
Age of Injured Party*

0-3 yrs4-8 yrs9-13 yrs14-17 yrsAdult
Date of Birth*
Sex of Injured Individual*

FemaleMale
Injury Site (Where on body did injury occur. Please be as detailed as possible)*
Breed That Caused Injury?*

Pit Bull TerrierDoberman PinscherRottweilerGerman ShepherdChowMixed BreedOther
If Other, Please Specify Breed*
Did Injury Result in Death?*

YesNo
Was Injured Party Insured At Time of Incident?*

YesNo
What Are Your Remaining Out of Pocket Expenses? (Co-insurance/Deductible Etc.)
What Service/Assistance Are You Seeking?*

Funeral/Burial CostsMedical ExpensesTravel/LodgingAccess to Victim Support GroupsCounselingOther
The County/State In Which the Injured Party Resides? *
Any Additional Pertinent Information? Please Share
Thank you for sharing this information with our team. Please note that the information you've provided is strictly confidential and not shared with any third parties. We will review the details provided and contact you as soon as possible.
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