Medical Application

Your Information

* required field

Your Name*

Street Address*

Home Phone*

(xxx)xxx-xxxx

Work Phone

(xxx)xxx-xxxx

Mobile Phone

(xxx)xxx-xxxx

Your Email*

Dog's Information

Name*

Breed*

Sex*
---MaleFemale

Spayed/Neutered*
---YesNoNot Yet

Adoption Shelter/Rescue*

Adoption Shelter/Rescue Phone*

(xxx)xxx-xxxx

Have you received funds from FFL previously?
 No Yes

Medical Information

Veterinarian*

Veterinarian Phone*

(xxx)xxx-xxxx

Funds requested for medical assistance*

Please provide a brief description of medical condition and veterinary care needed:*

Financial Need*

Medical funds are limited and therefore restricted to those who have a clear financial need. Please select a reason below for your financial need and attach proof. Failure to do so may result in significant delays or your application being denied.

 Full time student Unemployed Public Assistance Other

Proof of Need*

You must upload proof of need for your application to be considered. Documentation should be from an official source (e.g. government office or school registrar). Documents can be scanned and attached as a *.jpg or *.pdf.

 I have read and agree to the terms and conditions