ResQ Fund and Live for David Application

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

How can the ResQ Fund help?

The ResQ Fund is currently only available to pet owners living in the counties that compromise the Eastern Panhandle of West Virginia and to rescues that serve and help our area. If you do not live in Berkeley, Jefferson, Grant, Hardy, Morgan, Hampshire, Mineral, or Pendleton county, please refer to these sites that may be able to help you: www.redrover.org , www.friendsandvetshelpingpets.org or www.frankiesfriends.org.

If you live in our service area, please help us to understand your pet's needs by answering the questions below.

Please let us know in the space below the total number of pets in your household. Please include ALL pets.

For example, 2 dogs, 4 cats, 2 birds, etc.

Provide the following information regarding the pet(s) for which you are applying for assistance: Type/Name/Sex/Medical Needs

Example: Dog/Fido/Male/neuter and vaccines or Cat/Patches/Female/dental issues

All pets must be living in a healthy environment and good living conditions. Please check the answer that best represents your pet's living environment.

For cat colonies, please see the next question.

My pets live inside only. My pets live inside and outside. My pets live outside only.

Cat colonies: If assistance is being sought for outdoor cat colonies, please explain details of colony below. For example, location, number of cats requiring spay/neuter or other medical attention. If this is a TNR request, please indicated whether the cats may be returned to their colony.

Example: 12-15 cat colony located in Millville. Cats need spay/neuter and some medical care. Cats can be returned to colony after spay/neuter.

Are all of your pets up to date on rabies vaccinations? If they are up to date, please be prepared to present proof of rabies vaccines.

Some of my pets are not up to date on rabies vaccinations.Yes, my pet(s) is/are up to date on rabies vaccinations.No, my pet(s) is/are not up to date on rabies vaccinations.

To be approved to receive ResQ Funds, we require all pets in your household to be spayed/neutered, unless there is a compelling reason why they cannot be. Please check the answer below that best applies to your situation.

All of my pets are spayed/neutered.Some of my pets are not spayed/neutered, but I plan to have them spayed/neutered.Some of my pets are not spayed/neutered, and I do not intend to spay/neuter. One or more of my pets are not spayed/neutered because my vet advised against it for medical reasons.

Are all of your pets for companionship and not used for breeding or illegal activities? Please explain if any of your pets are used for breeding purposes.

If you have already received a copy of a written cost estimate for the needed procedures and/or treatment from your veterinarian, please upload here.

Please use the space below to share any additional information or questions that you may have.

Enter any clarifying information for any of the questions above.

For what type of medical services do you require assistance? Please check all that apply.

Life-Threatening Emergency Aid ("Live for David" $250 Maximum award)Spay/NeuterRabies VaccineOther vaccines, such as distemper, Bordetella, Feline Leukemia, etc.Minor Illness (upper respiratory, vomiting, urinary problems)Dental IssuesSurgery (enucleation, limb amputation, hernia repair, etc.)Other

If you do not receive help with your pet(s), what will you do?

I will surrender my pet(s) to our local shelter, because I will be unable to care for them.I will look for a rescue that can provide medical care for them, because I will be unable to care for them.I would consider euthanizing them because I have no other means to pay for their medical care.I will keep looking for ways to help them so that I can get them well and keep them.

Will you need help with transporting your pets to and from vet for care?

Please check yes if you need to use our ResQ Shuttle service to transport your pets to the vet. Our ResQ Shuttle Manager will be in touch. You will also need to sign a release of liability form to use the ResQ Shuttle.

Yes, I will need help taking my pets to and from the vet. No, I can provide my own transportation.I am not sure. I may be able to take them depending on where and time of day.Yes, I will need help taking my pets to the vet but will be able to pick them up myself.Yes, I will need help picking my pet up from the vet but can drop them off in the morning myself.

Are you applying for spay/neuter assistance through the WV Spay and Neuter Program (WVSNP)?

YesNoI don’t know what that is.

Agreements and/or Acknowledgements

Please read and consent to the following.

May we text you?

YesNo

Do you object to having your name checked through the local court system?

YesNo

If you have a veterinarian, do you give us permission to contact them for a reference, if one is needed. If yes, please enter the name and telephone number of the veterinary practice that you are currently using.

If you do not have a veterinarian, please indicate below.

By signing below, I attest that the information provided is truthful. The undersigned hereby releases To the ResQ, The ResQ Fund and all representatives associated therein, from any and all liability related to any services obtained related to this request. Typing my full name below serves as my signed agreement to and understanding of all of the requirements and statements as indicated in ResQ Fund program guidelines.

Please enter your full name below.

Example: John Edward Smith

Please enter today's date below.

Example: December 10, 2022

Eligibility Questionnaire

Please answer the following questions and provide the requested documentation.

This form is for pet owners only. Rescue organizations: please contact us at theresqfund@gmail.com.

IF YOUR PET IS HAVING AN EMERGENCY OR LIFE THREATENING ISSUE, PLEASE SEEK IMMEDIATE ATTENTION! FUND MAY NOT BE IMMEDIATELY AVAILABLE.

The following application is for individuals seeking financial aid from To The ResQ's veterinary assistance program. Financial assistance for non-urgent veterinary expenses, such as spay/neuter, vaccines and minor illnesses is available through The ResQ Fund. For life-threatening illnesses and/or emergencies, a maximum grant of $250 per incident/illness per pet may be available through the "Live for David" program.

All funds will only be paid directly to a veterinary practice. No funds will be given directly to an individual.

To The ResQ does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.

Please explain your current situation and why you are requesting financial assistance through the ResQ Fund. This program is designed to help with spay and neuter costs, and urgent veterinary needs for people who cannot afford care. This fund is limited to a maximum of $250 which is intended to diagnose and/or triage your pet.

Please include information like your current job status (unemployed, employed, retired, student, part-time, disability etc.) or recent change(s) to your income which have led you to need assistance at this time.

Please check answer which best describes your current employment status:

Employed full-timeEmployed part-timeRetiredStudentUnemployedUnable to Work, Receiving Disability/SSI

Do you currently receive any Human Social Service Assistance? Check all that apply:

SNAPDisability/SSIMedicaidUnemploymentWICI am currently not receiving any assistance, but am suffering financial hardship.

If you are receiving any of the benefits referenced above, please upload one document showing proof of financial need, such as unemployment status, disability, social security, SNAP benefits, etc.

If you indicated above that you are receiving social services in the question above, you will be asked to provide proof before being approved so please upload documents. This may fast-track your application. All information will be held confidentially.

Applying to Care Credit (carecredit.com or 800-677-0718) is a requirement for eligibility. Have you applied for and received Care Credit?

DO NOT SKIP THIS STEP! If you have not applied for care credit, please stop and do that now. Be prepared to show proof of your application approval/denial. You will be asked to show a screen shot of your application status. NO APPLICATIONS WILL BE PROCESSED WITHOUT APPLYING FOR CARE CREDIT FIRST - even if you decide not to take the loan.

Yes, I have applied, but was denied Care Credit.No, I have not applied for Care Credit at this time.Yes, I have applied and was approved, but it is still a hardship for me to pay.

Please upload a copy of your approval/denial from Care Credit.

Applicants must make an attempt to apply for Care Credit before we can approve an application.

On your application for Care Credit, you were asked to indicate your monthly income. Which range below best reflects the number you used to indicate your monthly income from all sources in your household?

$0 to $1000 monthly income$1001 to $2500 monthly income $2501 to $4000 monthly income $4001 to $5500 monthly income$5501 to $7000 monthly income$7001 to $8500 monthly income$8501 to $10,000 monthly income$10,001 to $15,000 monthly incomeOver $15,000 monthly income

Is there anything you would like to tell us about your pet or why you need our help that you feel would be beneficial for us to know when deciding your application?

We aren’t always able to award 100% of the costs of services needed. For some awards, we may only approve a partial award. Are you willing or able to contribute a small percentage towards these services?

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