BirchBark Foundation, Inc. · Grant Application

Please fill out all fields to your best ability. Those fields with a red asterisk (put "0" or "none" if needed) must be filled out or the application will not submit.

Name

*

First Name

Last Name

Mailing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

*

Phone

*

Email

*

Verify Email

*

Is there an alternate contact for this case?

*

Yes

No

Alternate Contact Name

First Name

Last Name

Additional Phone

How many adults are in your household?

*

Please type a number

How many children (under 18) are in your household?

*

Which of the following apply? (Please check all that apply.)

This information is optional and helps us with future fundraising.

Unemployed

Disabled

65 or over

Active Military

Veteran

Student

Homeless

None

Have you applied for Care Credit?

*

This is a requirement to apply for assistance.

Yes

No

If approved for Care Credit, what is the amount?

Employer Name

*

Please write your place of employment (if none, write n/a)

Employer Phone

What is the annual household income?

*

Please include the combined income of all residents.

Pet Name

*

Species

*

Dog

Cat

Breed

*

Sex

*

Male

Female

Age

*

Photo of Pet Only

THIS IS A REQUIREMENT FOR BIRCHBARK FINANCIAL ASSISTANCE. If you are unable to upload photo, please contact us at info@birchbarkfoundation.org or 831.471.7255.

Photo of Family with Pet

Additional Photo of Pet

Pet Photo Release

*

By submitting this application, I am granting permission to BirchBark to use photos of my pet (not including human family) for promotional purposes. I waive any right to inspect or approve the use of the photograph and/or recording, and acknowledge and agree that the rights granted to this release are without compensation of any kind.

Yes

I grant BirchBark permission to use photos of my pet *including human family* in their online and/or print publications.

*

Your response to this question will not affect the outcome of this application.

Yes

No

Spayed or Neutered

*

Yes

No

If NO, why not?

When did your pet join your household?

*

(mm/dd/yyyy)

Where did your pet come from?

*

What does your pet mean to you and/or your family?

*

Are there other pets in the home? If so, please list their species, age, and spay/neuter status.

*

Describe your pet's injury or illness. How did the injury occur?

*

When did this injury/illness first occur?

*

(mm/dd/yyyy)

Is your pet at the hospital now?

*

Yes

No

How much have you already paid for treatment for this injury/illness?

*

Describe the circumstances that are keeping you from being able to afford your pet’s treatment.

*

PLEASE NOTE: BirchBark Foundation grants can help with funds after your available resources have been used including, but not limited to, banking accounts, Care Credit, retirement funds, savings, or loans from friends and family.

How did you hear about BirchBark Foundation?

*

If you have created an online fundraiser, please list the web links here:

What Pet Insurance do you have?

Hospital Treating your Pet

*

BirchBark can only fund pets that are being treated at one of our Veterinary Partner Hospitals.

Hospital Phone

*

Does BirchBark Foundation have your permission to speak with your veterinarian about this case?

*

Yes

No

Bank Statements

Please upload your last 2 months of bank statements. THIS IS A REQUIREMENT FOR BIRCHBARK FINANCIAL ASSISTANCE.

1st Month Bank Statement

2nd Month Bank Statement

Tax Returns

Last Years' Tax Return

Please upload last year's tax return here. THIS IS A REQUIREMENT FOR BIRCHBARK FINANCIAL ASSISTANCE.

APPLICATIONS ARE NOT CONSIDERED COMPLETE WITHOUT YOUR LAST 2 MONTHS OF BANK STATEMENTS AND LAST YEARS' TAX RETURN.

IF YOU ARE UNABLE TO UPLOAD PLEASE SEND TO INFO@BIRCHBARKFOUNDATION.ORG.

Please read all of the following and check if you understand and agree:

*

I agree that the information provided above is true to the best of my knowledge.

*

If approved, BirchBark provides funding for up to 50% of the bill and Veterinary Partners discount 25% from their services. The pet family may have to use a portion of the available Care Credit amount towards the pet's treatment. The pet family and hospital must come to a payment agreement for the client's portion of the bill, which will be a minimum of 25% of the total bill.

*

All animals that receive BirchBark funding must be spayed or neutered. If an animal is not spayed/neutered at the time funding is given, the pet family agrees to have their pet spayed or neutered during funded treatment if possible, or within a set time frame determined by the treating veterinarian.

*

If approved, I agree to allow BirchBark to document my pet's success story within a month of treating my pet so that donors can learn about the successful outcome of my pet.

*

I understand that BirchBark may ask other funding sources to assist in paying for the veterinary care needed and I hereby consent, in connection with my request for financial assistance from BirchBark, to BirchBark providing any and all financial, personal and credit information that I provide to BirchBark to other potential funding sources.

Please fill out all fields to your best ability. Those fields with a red asterisk (put "0" or "none" if needed) must be filled out or the application will not submit.

Bank Statements

Tax Returns

READY TO SUBMIT? AFTER YOU SUBMIT, YOU WILL SEE A "THANK YOU" PAGE APPEAR. IF NOT, GO BACK AND SEE WHICH FIELD WITH A RED ASTERISK YOU LEFT BLANK.