EmailMe Form - Captain's Salute Financial Aid Application

Pet Owner's Name *

First Last

Pet's Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Have you applied for and received a Captain's Salute Care Package? *

Yes

No

Please upload documentation on your vet practice's letterhead of your pet's Wobbler Syndrome diagnosis. Diagnosis must have been determined via CT or MRI by a licensed veterinarian or specialist. *

Does your pet have insurance? *

Yes

No

Pet Insurance Provider *

Enter "N/A" if you do not have pet insurance.

Please upload a copy of your insurance policy dec page (page from the policy that includes coverage limits and any exclusions).

If you are unable to attach to the application, you will need to email us a copy at captainssalute@gmail.com. We cannot move forward with your application until we receive this information.

How much of your deductible has been met at the time of your application? *

Enter "N/A" if you do not have pet insurance

Do you have any personal fundraisers posted (e.g. GoFundMe)? *

Yes

No

We are happy to share these for you on our social media account!

Have you applied for financial aid with any other organization? *

Yes

No

Please list your personal fundraisers (include any links) and other organizations for which you have applied for financial aid. Please indicate if you were approved or denied the financial aid - if denied, let us know the reason. *

Enter "N/A" if this does not apply

Have you applied for Care Credit? *

Yes

No

Was your Care Credit Approved? *

Approved

Denied*

N/A

*If you were declined for Care Credit, Captain's Salute may require proof of denial

If approved for Care Credit, please enter amount approved for *

Enter "N/A" if this does not apply

Vet Practice Payment Would be Sent to *

Vet Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

At this time, the vet must be in a US-based location.

Date of Procedure *

MM / DD / YYYY

Name/Type of Procedure *

Please attach a copy of the estimate provided by the vet.

If you are unable to attach to the application, you will need to email us a copy at captainssalute@gmail.com. We cannot move forward with your application without this information.

Please let us know a little about your family, pet and reason for applying for financial aid. *

Captain’s Salute may post social media campaigns in order to help raise money for your pet’s needs and request for financial assistance. Our social media campaigns also enable us to grow our network and help reach other Wobblers families. If approved for financial aid, you will be asked to provide photos of your pet along with a short bio of your pet that includes details you don’t mind sharing. You may opt out of the social media item, but please note that opting out may impact the amount of funding available for financial aid. *

I agree to share pictures of my pet and my pet's story to be shared on social media.

I would like to opt out of sharing any information on social media.

Please provide us with your social media account handles/screen names. *

Acknowledgements & Disclaimer:
Funding - The amount of funds available are subject to change at any given time depending on the volume of requests for care packages, financial aid, and successful fundraising activities. By submitting an application for financial aid, you acknowledge that approval and/or the availability of funds may not be guaranteed.
Care of Pet - Captain's Salute is comprised of volunteers; we are not licensed veterinarians or vet technicians. Any advice provided by Captain's Salute is solely based on personal experiences with Captain's care and shared experiences from other #TeamCaptain Wobblers families and should not be deemed as a recommendation of care for your pet. Recommendations for your pet's care should be provided to you by your veterinarian.

Please check the box below to indicate you have read and understand the previous statement and that you acknowledge the information in your application is truthful. *

I have read and understand the above statement and agree that the information in my application is truthful.