Emergency and Specialty Care Assistance Program

*If you believe that your pet's life is in immediate danger, you should apply here, but seek immediate assistance from a licensed Veterinarian. We will consider assisting in cases where treatment has already occurred if the pet's life was truly at risk, provided you complete this questionnaire within 7 days of the onset of the injury/illness. *

Thank you for reaching out to St. Nicks Closet 501(c) (3) non-profit organization whose mission is to assist families and their animals with emergency and specialty care in Fayette and Coweta County. Our primary goal is to offer families in financial crises an alternative to euthanasia when their pet has a treatable, yet life-threatening condition. In an effort to provide optimal care for both families and pets, we will work with the family's primary vet, or one of our partnering clinics to offset or cover care costs for the pet. The level of assistance to families is commensurate upon availability.

Please see the following guidelines in order to receive assistance from THF:

Due to limited funding availability, only families in the Fayette/Coweta, are eligible for consideration.

Award value is commensurate on availability in order to allow us to help as many animals and families as possible.

We are currently setup as a one-time benefit for emergency care, life-saving surgery or treatment, and in some cases, temporary assistance for critical specialty care, such as diabetic medications.

Approval for funding is based on the families’ current financial situation and the companion animal’s diagnosis/prognosis.

Assistance is only approved for procedures that a licensed veterinarian has diagnosed, recommended, and believes will improve an animal’s quality of life. A statement from the veterinary practice reflecting the necessity of the procedure and said procedures impact on the quality of life is required.

Owners must show responsible pet care (pet spayed/neutered and up-to-date with vaccinations, etc.).

If there are any signs of neglect or abuse, assistance will be denied and the proper authorities will be notified.

St. Nicks Closet does not currently help with routine vet visits/care, medication, spay/neuter, vaccines, etc. We do hope to hold specialty events with partnering veterinary practices to offer these at little to no costs.

St. Nick’s closet is an assistance fund and unfortunately cannot always cover the complete costs.

If your animal’s veterinarian feels that the above requirements are met, please submit your application along with all required documents. Awards are distributed subject to the discretion of the Board of Directors of St. Nicks Closet

**Application on the following pages**

Application for Assistance

We want to ensure our assistance reaches as many families and animals as possible. As our program is mainly financial assistance, we request proof of at least one of the following items in order to qualify. We recognize that some families do not meet any of the items below, yet are still in an extraordinary financial crises. If you are not able to meet one of the items below, please send us a detailed explanation of your situation and we will review.

For all items below, please hide any personal information like social security numbers. While we will not share your information with anyone, we prefer that all steps are taken to ensure your privacy.

Verification Document List:

Documentation showing current enrollment in state or federally funded welfare program.

Food Stamps.

Denial Letter from Care Credit or similar credit program.

Last two pay stub proving income meets state or federal low income or WIC guidelines.

Medicaid.

SSI Disability.

Proof of unemployment – current within last 30 days.

Military I.D. showing active military status (non-commissioned).

Insurance claim or other official documentation, showing recent, loss of home due to natural disaster, etc., or extraordinary expense.

For our records, we also ask that you provide a brief story about how your pet came to live with you and how you came to need the assistance of St. Nicks Closet

Currently, we serve the Fayette/ Coweta area only. Requests from outside this area will be taken into consideration; however, we cannot guarantee assistance. Our finances change daily and assistance is commensurate to availability.

Our assistance is approved based on three main components; responsible animal care, the animals diagnosis and quality of life, and your household financials. As a result, we need you to answer every question honestly and completely. Please elaborate whenever possible.

Personal Information:

First and Last Name

Street Address	City

State	County	Zip

Email	Phone

What is the urgency?

The animal in need is my pet: Yes	No

Please briefly describe the situation:

Financial Information:

What is the estimated cost for treatment: $

What amount can you pay? $. (We ask that all recipients of our award pay some portion of the costs.)

Have you received any other donations or support you can contribute, if yes, how much?

Do you have pet care insurance and if so, what amount will your policy reimburse?

Are you currently employed?

Do you currently rely on government assistance?

What is your current household income?

Which item(s) from the above verification documents list can you provide?

Pet Information:

Name	Type (dog, cat, etc.)

Age	Already spayed / neutered?

If not spayed / neutered, please explain why

How long have you and your pet been together?

Is your pet a rescue animal?	How many pets do you have?

Do you breed any animals?

Have you ever entered your pet into a breed-specific, agility, or any other type of contest?

Veterinary Information:

In some cases, we may need a second opinion from one of our partnering veterinarians and may direct you to them for additional diagnosis and, or treatments. St. Nicks Closet will make every effort to work with your primary veterinarian. For this reason, we do require contact information for your veterinarian and practice.

If you have been referred to a specialist or have taken your pet to an emergency facility, please include the contact information for this facility (name of clinic, name of doctor, address, phone number, and office email) in the comments section below.

Primary Veterinary Clinic Name:
Primary Veterinarian's Name: (leave blank if doctor's rotate)

Clinic Address:

Vet's Phone:	Vet's FAX Number:
Clinic or Doctor's Email:

Comments & Description of pet's medical needs and/or Specialist's contact information: