Actors and Others for Animals : Emergency Medical Assistance Application

Programs:

PLEASE READ GUIDELINES, INSTRUCTIONS AND REQUIREMENTS
BEFORE PROCEEDING! CLICK HERE

We do our very best to assist as many people as possible and respond to applications in a timely manner. Our medical counselor will call to discuss applications, so be sure to provide a phone number where you can be reached. Because of the overwhelming number of applications we receive, do not expect an immediate response. We will attempt to respond within a week to 10 days. We cannot guarantee that we will be able to respond to every application. If you do not hear back from us within a week or 10 days, we will not be able to assist you. Our office is open Monday through Friday from 9:00 a.m. through 4:00 p.m.

Our medical helpline telephone number is 818.752.6725 at which you may leave a message. Again, due to the number of messages received, we may not be able to get back to everyone in a timely manner. Do not call the general number of Actors and Others in an attempt to reach the Medical Department to expedite your application. You will simply be referred to 818.752.6725.

Please remember that we are limited with regard to both funds and personnel. So your understanding is very much appreciated.

IF YOUR PET IS IN NEED OF IMMEDIATE CARE WHERE ANY DELAY WILL PUT THE ANIMAL AT RISK, IT IS YOUR RESPONSIBILITY AND DUTY TO GET THE ANIMAL TREATMENT. DO NOT WAIT FOR A RESPONSE TO YOUR APPLICATION AS THERE IS NO GUARANTEE WE WILL BE ABLE TO PROVIDE YOU WITH ANY FINANCIAL ASSISTANCE.

All fields marked as *required must be completed for the application to be considered. Please be sure to double-check that your telephone numbers are correct and that you are truthful as to the amount of funds you are able to pay towards your pet’s treatment.

After you hit the “Send It,” button, a page will immediately pop up saying “Thank You!” with a picture of a smiling Collie. You will then receive a confirmation email with a copy of your application. This does not mean your application was approved; only that it was received. If you leave any of the questions blank a computer page will pop up saying that “You left the [question] blank.” You must go back and complete the entire application. Be sure you check that you have read the guidelines.

* These fields must be completed for the application to be considered.

I have read and understand the guidelines, instructions and requirements. I further understand that while Actors and Others endeavors to respond to everyone, due to the overwhelming amount of applications submitted, I may not hear back at all, and that it is my responsibility to seek treatment for my pet.

*First Name Owner/Guardian:

*Last Name Owner/Guardian:

*Address: NO P.O. BOXES!

*City:

*Zip Code:

*Day Phone:

*Alternative Phone:

*Email Address:

*Confirm Email Address (re-enter):

If someone other than the owner/guardian is assisting in the completion of this application, please provide your contact information.

First Name Contact:

Last Name Contact:

Address of Contact:

City:

Zip Code:

Day Phone of Contact:

Alternative Phone of Contact:

Email Address of Contact:

*Received Help from AOA in the last 2 calendars years

Yes or No?

*How did you hear about us?

*Are you seeking help for your own pet?

Yes or No?

*Pet's Name:

*Species - Dog, Cat, Rabbit, Other:

*Breed

*Sex of Pet

*Age

Male or Female

*Where did you obtain your pet, e.g. friend, stray, rescue group, animal shelter (which shelter).

*Is your pet spayed or neutered?

Yes or No?

*If not, will you agree to sterilize your pet at the time of treatment if possible?

Yes or No?

*Describe your financial hardship:

*What is your household annual income? (The combined income of everyone living in your home and contributing to your household expenses).

*Describe the animal's injury/illness, how long the animal has
been sick and cause of any injury:

*What is the medical finding as to what is wrong with your pet?:

*What are the medical services needed?:

*Will such services cure your pet?:

*If not, why and what other services will be needed?:

*What is the cost of treatment?:

*How much are you able to pay toward the cost as of today?:

*List any donations you have received from other organizations
and the amount of the donation:

*Name of Veterinarian/Clinic

*Address:

*City:

*Zip Code:

*Phone:

Fax:

Contact Name:

*Is the veterinarian/clinic willing to bill Actors and Others?

Yes or No?

*If Actors and Others provides financial assistance, will you send in photographs and a description of help provided for use by Actors and Others in promoting this program?

Yes or No?

By submitting this application you declare that you have read the guidelines and understand the requirements to receive assistance.

Remember: these fields * must be completed for the application to be considered.

Privacy Policy: Actors and Others for Animals respects your privacy, and will never sell, loan, lease, give or exchange your information. A Non-Discrimination Policy is on File.