BT Rescue Organization Application

Rescue Organization Grant Application

About Your Rescue organization
What is the name of your rescue organization?
Note: only pre-approved rescue organizations can submit applications. Contact us to see if you qualify for pre-approval.
If you choose "Other Rescue Organization," please explain:
Who is the primary contact for your rescue organization?
Phone number*
Do you have authority to approve this rescue and related medical treatment?
- Yes
- No
If not, who does?
Approver Title:

e.g., Mr, Mrs, Ms, Private, Lance corporal
Approver Name*
First Last
Approver Phone Number*
Approver Email Address*
Why do you need help from Broken Tails?
About Your Foster Family

All rescue organizations requesting Broken Tails assistance MUST have foster family lined up to provide care for the pet seeking treatment.
Title / Military Rank

e.g., Mr, Mrs, Ms, Private, Lance corporal
Name*
First Last
Age
Please enter a number from 18 to 100.
Address
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Email Address*
Enter Email Confirm Email
About Your Pet(s)
What is the name of pet seeking treatment:
What is the breed (e.g., lab, siamese)?
How did the pet get sick/injured?
How did your rescue organization get involved with this pet?
Diagnosis, medical treatment, symptoms or injury:
About Your Veterinarian and Payment Contribution
Name of treating clinic
If you choose "Other," please explain:
Note: only pre-approved Veterinarians can submit applications. Contact Us to see if you qualify for pre-approval.
Name of Vet
Name of Vet
Clinic Phone
Clinic Phone
Estimated cost of proposed treatment:
Amount you can contribute:
Other Info
Is there any other information that you want us to know?
Requirements and Signature

I affirm that the information I have provided is complete and accurate. I give my consent for the above-mentioned medical care. I understand that Broken Tails assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services. I consent to give Broken Tails use of any pictures provided of my pet or its owners as well as a description of the medical care to help in promotion and fund raising. I understand any pictures given to Broken Tails cannot be returned.
In order to receive financial assistance for my pet, I must:
- BE 18 YEARS OF AGE OR OLDER.
- Have identification showing my affiliation with my rescue organization.
- Have authority to speak for the rescue organization.
- Understand that it is my responsibility to find appropriate foster care and monitor the foster family to ensure this pet has:
- Understand that if the foster family has other cats/dogs that go outdoors that they need monthly heartworm along with flea and tick preventative treatments.
- Understand that all cats/dogs that receive Broken Tails funding MUST be spayed or neutered. I consent to have this cat/dog spayed or neutered during this procedure or within a set time frame after the procedure based on the health of the cat/dog.
- Understand that this application is the property of Broken Tails and will be retained in its files.
- Understand that Broken Tails has full authority to approve or deny my application.
- Understand that Broken Tails reserves the right to verify all information submitted on this application, including veterinary information.
By selecting ‘I Agree’ below, I affirm that I understand and accept Broken Tails requirements, payment policies, as outlined above and detailed on the Grants page. It also certifies that the information I have supplied above is true and that any false statements may result in nullifying this application. I further understand that this application is the property of Broken Tails and will be retained by them.
By selecting ‘I Agree’ below, it constitutes an electronic signature that is valid and a legal substitution for my written signature.

Date

By checking this box you have read and agree to the above statements*

I agree

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