Applicant Details

First name*

Last name*

Multi-line address

Country/Region*

Address*

Address - line 2

City*

Zip / Postal code*

Email*

Phone

Support Requested

Please select the type of support you are applying for:*

Hydrotherapy

Physiotherapy

Other rehabilitation support

Financial assistance towards treatment

Other

Dog's Name*

Breed

Age

Registered Veterinary Clinic*

Condition/Injury*

Current Treatment

Please select one:*

Fully funded rehabilitation

Partially funded rehabilitation

Other

Please provide details about your current financial circumstances and why assistance is being requested.

Examples may include:

To help us assess your application fairly, please upload supporting evidence of financial hardship or low income.

Examples of accepted documents may include:

(Please do not upload bank card details or sensitive financial passwords.)

File upload

Please provide any additional details you feel may support your application.

I confirm that the information provided is accurate and understand that supporting evidence may be required to process my application.

I agree to the Rehabilitation Fund reviewing the information provided for the purpose of assessing financial assistance.

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