Apply for Wheelchair

Applications are reviewed 3-4 times a month; all applicants are promptly notified by email whether they have been denied or awarded a wheelchair grant.

Wheelchair grants will be held for 7 days; if not ordered during that time the grant will be awarded to another applicant.

Your Information

Full Name(*)

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E-mail(*)

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Street Address(*)

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City(*)

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State(*)

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Zip(*)

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Phone(*)

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Your Pet Information

Pet Name(*)

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Species(*)

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Breed(*)

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Age(*)

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Weight(*)

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Gender

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If you wish to submit a photo of your pet you may do it here

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Pet Health Information

Describe Pet's overall health(*)

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Cause of mobility loss(*)

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Describe pet's condition and length of time disabled

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What is the veterinarian's diagnosis, prognosis or recommendations?

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List the specifics of what your pet needs

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Is there anything else you'd like us to consider as we review your application?

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Proof of Hardship

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Applications who attach proof here will be given consideration first.

In order to make sure that our assistance goes to the families who need it the most, we ask that you show us that you are already receiving support from state or local government assistance programs. Proof of financial hardship involves a document in your name that shows you are getting state aid or assistance. These include disability, welfare, food stamps, section 8 housing assistance, TANF, and more. Please upload a scan or photograph the document or mail a copy to our address (copies will not be returned).

Applications are reviewed 3-4 times a month; all applicants are promptly notified by email whether they have been denied or awarded a wheelchair grant.

Wheelchair grants will be held for 7 days; if not ordered during that time the grant will be awarded to another applicant.

(*)

I give Handicapped Pets Foundation permission to publish any pet photos or videos I submit in any and all of its printed or web-based publications without compensation. Invalid Input

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