Application for Services

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

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

First Name Last Name
Date of Injury *

Month Day Year
Date
Age of Injured Party *

0-3 yrs 4-8 yrs 9-13 yrs 14-17 yrs Adult
Date of Birth *
Sex of Injured Individual *

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

Pit Bull Terrier Doberman Pinscher Rottweiler German Shepherd Chow Mixed Breed Other
If Other, Please Specify Breed *
Did Injury Result in Death? *

Yes No
Was Injured Party Insured At Time of Incident? *

Yes No
What Are Your Remaining Out of Pocket Expenses? (Co-insurance/Deductible Etc.)
What Service/Assistance Are You Seeking? *

Funeral/Burial Costs Medical Expenses Travel/Lodging Access to Victim Support Groups Counseling Other
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.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform