Los Huerfanos Animal Welfare Association Financial Assistance Application

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Los Huerfanos Animal Welfare Association Financial Assistance Application

This is an application to receive financial assistance for basic veterinary services (spay or neuter, vaccinations, and micro-chipping) with a local veterinarian in Huerfano County.

You must be a Huerfano County resident to receive services.

This application helps us determine what services are needed and the final cost for you and us.

Most of the funding we receive is through grants and requires that the pet(s) you are applying for are owned pets.

The purpose of collecting this information is for grant reporting. All information is confidential and kept secure. We will never sell your information.

Upon review of your application, we will contact you with cost estimates. We will also provide you with instructions on scheduling with the veterinarian. You are responsible for booking the veterinary appointments.

I understand that LHAWA provides financial assistance to pet owners for the cost of spaying or neutering, vaccinations, or micro-chipping services that will be completed at a veterinarian's office and there is a portion of the cost that I must pay at the time of my scheduled appointment.
*

Yes

I understand a veterinarian is providing the services and LHAWA holds no liability in medical outcomes or additional services you receive. *

Yes

Do you live in Huerfano County? *

Yes

Are you the pet owner? *

Yes

Do you qualify or receive any public assistance? *

Yes

Are you employed?

Yes

Retired

Disabled

What is your yearly income range?
*

Under $30,000

$30,000 - $50,000

$50,000 - $75,000

$75,000 - $100,000

$100,000 - $150,000

$150,000 - $200,000

Other:

I understand that if I need to reschedule my original appointment that this must be done directly through the veterinarian 24 hours before the date of the procedure.
*

Yes

I understand that if I NO CALL/NO SHOW my appointment, I will be forfeiting assistance for 6 months and will be able to reapply again for services after 6 months has passed. *

Yes

I understand If I NO CALL/NO SHOW the second appointment, I understand that I will be forfeiting SNAP assistance indefinitely. *

Yes

First Name *

Last name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

What is your preferred method of contact? *

Phone Call

Text

What is the best time to contact you? *

Morning

Afternoon

Evening

What services are you requesting today? *

Spay/Neuter

Parvo Distemper Vaccine (dog)

Feline Leukemia Vaccine (cat)

Rabies

Microchip

Required

Dog or Cat?
*

Dog

Cat

Gender *

Male

Female

Pet Name *

Birth Year
*

Pet Breed *

Approximate Weight *

Does the pet have any health care problems or medical problems?

Is your pet currently pregnant? *

Yes

I don't know

Is your pet in heat? *

Yes

I don't know

If you see a veterinarian, what is the veterinarian's name or the vet clinic name?

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