About the Pet Owner Name*
First
Last
Mailing Address*
Is the person submitting this application 18 or older?* Please note that the applicant must be 18 years of age or older. Minors may submit an application on behalf of an adult as long as the applicant's name is the adult's. The minor may include themselves as an alternate contact.
Is there an alternate contact for this case?* Alternate Name
First
Last
Alternate Address
Have you ever received a RedRover Relief or LifeLine Grant?* When?* Are you applying again after a previous grant request was denied?* What is the annual household income?* Select One less than $10,000 $10,000 - $25,000 $25,001 - $40,000 $40,001 - $60,000 $60,001 or more
If your yearly household income exceeds $60,000, unfortunately, you do not qualify for a RedRover Relief grant. Please be sure to visit www.RedRover.org/help to view our list of other financial assistance programs that may be able to help.
We understand that veterinary care is expensive. Please share information about your specific circumstances and why this care is difficult to afford.)*
Which of the following apply for you?* (Please check all that apply.)
How did you hear about us? How do you publicly self-identify? Female Gender nonbinary/Genderqueer/Gender non-conforming Intersex Male Select One
How do you publicly self-identify? Asian American/Pacific Islander/Asian Black/African American/African Hispanic/Latino/Latina/Latinx Native American/American Indian/Indigenous White/Caucasian/European Multi-racial/Multi-ethnic (two or more race or ethnicities) Different identity (specify below) Select One
How do you publicly self-identify? Gay, lesbian, bisexual, pansexual, asexual (or other sexual orientations within the LGBTQIA+ community) Heterosexual or straight Different identity (specify below) Select One
How do you publicly self-identify? Gender nonbinary/Genderqueer/Gender non-conforming Not Transgender (cisgender) Transgender Select One
How do you publicly self-identify? As a person with disabilities. As a person without disabilities. Select One
About the Animal Species* Dog Breed Select One Beagle Boxer Chihuahua Dachshund German Shepherd Golden Retriever Labrador Retriever Pit Bull Pomeranian Poodle Pug Yorkshire Terrier Other
Cat Breed Select One Domestic Cat Maine Coon Persian Ragdoll Siamese Other
Sex* Spayed or Neutered?* If not spayed or neutered, what are your plans to have this done?*
When did the animal join your household?* Is this a service animal?* A service animal is defined as a dog (or miniature horse) trained to perform a specific task or tasks to help a person with a disability. An emotional support animal is not considered a service animal.
Where did the animal come from?* Select One Rescue Organization Animal Shelter Online Ad Breeder Found Other
What does this animal mean to you and/or your family?*
Are there other animals in the home? If so, please list their species, age, and spay/neuter status.*
If available, please submit a photo of the animal. A "regular" photo is preferred – it is not necessary to depict the injury in the photo. Max 50 MB, .gif, .jpg or .png. Press the Upload button after selecting the image to upload. Multiple images can be uploaded one at a time.
About the Animal's Injury or Illness and Treatment Describe the animal's injury or illness. How did the injury occur?*
Do you have a diagnosis and treatment plan for this injury or illness that was given by a veterinarian within the last 30 days?* What date was the animal seen by a veterinarian?* If you do not know the exact date please use an approximate date.
When did this injury/illness happen?* Is the animal being treated at the hospital now?* When was the animal admitted to the hospital?* Is treatment scheduled?* When is treatment scheduled to happen?* What treatment has been provided, if any?*
What treatment is still needed?*
Have you applied for help with other organizations?* Please list all organizations that have been applied to for financial help. Please also note if the request has been approved, declined or is still being processed, and any amounts that have been pledged toward this animal's care.*
For the best chance to raise the needed funds, we highly recommend submitting applications with multiple assistance programs. For ideas on where to apply, please visit our resource list of other financial assistance programs at www.RedRover.org/help.
Have you applied for Care Credit and been approved?*
About the Clinic Treating the Animal Clinic Address*
Clinic Contact Name
First
Last
If you already have an estimate for veterinary care, please attach it. Having this information will help us to process this application more quickly. If uploading a picture, please make sure that the page is as flat as possible (not folded or crumpled), that the full page is included, and that it is in focus.
I have read and agree to the grant qualifications. By submitting this application, I agree that it has been completed in good faith. I understand that incomplete applications and/or the submission of false information may result in my application being denied. Please note that this form can time out. If that happens you will not be able to submit the application; you will need to refresh the page and reapply. If you have to refresh and reapply, you may want to copy the longer answers to another document (Word, Notepad, etc.). That way, when you refresh the page you'll have those answers ready to paste into the application.
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