Caring Aid, Rescue and Education for Border Collies

		For information or if you need help you can send us an email to: care4bcs@sbcglobal.net

Mission Statement | Funding Guidelines | Application Procedures | Apply for Aid | CARE4BCS HOME

Funding Application

Contact Information
Name:
Address:
City:
State and Zip Code:
Telephone No:
Email:
Dog Information
Name of Rescue Organization:
Name of Rescue Dog:
Sex of Dog:	Male Female
Description of Appearance of Dog:
Age of Dog:
Has the dog been neutered/spayed:	Yes No Not Yet
Circumstances surrounding why this dog came into rescue:
Do you know anything about this dog's background:
What are the foster plans for this dog:
Medical Information
Is this a life or death emergency:	Yes No
Please provide a full description of the rescue dog's illness or injury:
Dog's current location is:	Veterinarian Clinic Shelter Private Home Other
Name of treating veterinarian:
Name of clinic or practice:
Address of clinic or practice:
City:
State:
Postal / Zip Code:
Telephone Number:
Fax Number:
Email Address:
What is the dog's medical diagnosis:
What is the recommended course of treatment:
What is the dog's prognosis:
What is the estimated cost of this treatment:
Was a rescue discount requested:	Yes No
If yes, will one be granted:	Yes No
Has treatment already begun or been completed:	Yes No
If so, what date:
Funding Information
Have your contacted any other organizations regarding this dog? If yes, identify organization, give contact person's name and information, and summarize their response to your situation:
How much have you already spent on this dog's medical treatment and care since rescue:
CARE4BCS' funds are always limited, but we try to help as many border collies/border collie mixes as we can. How much will you or your rescue group be able to contribute to this bill:
Please specify the amount you are requesting from CARE4BCS:
If you are financially unable to contribute to this dog's care, please explain:

I have read CARE4BCS' Mission Statement, Application Procedures, and Funding Guidelines and if funding is approved I agree to abide by all rules and contigencies set forth by the organization.	Yes No

If you have any questions or problems submitting this form, OR IF YOU DO NOT HEAR FROM US WHITHIN 48 HOURS, please email us or call 608-547-7988.