AHF-SCVMA Boydston Grant Hospital Enrolment Form

SCVMA and Animal Health Foundation Angel Fund Grant Hospital Enrollment Form

Please fill out this page completely for consideration for ABoydston eligibility

APPLICATION REQUIREMENTS

This application needs to be completed and submitted once.

By filling out the information below, this hospital agrees to the following:
* Our hospital has at least one current SCVMA member veterinarian
*We agree to share information about the case and the client including a high resolution photograph of the pet and owner
*We agree to screen the client for needs and age PRIOR to submitting the application
*We understand there is a limited amount of funding and we are only eligible for $1000.00 per year.
*We understand that any activity that might be considered fraudulent will be reported to the appropriate authorities.
*We understand NOT everybody in need can be assisted.
*We agree to help further the AHF-SVMA Boydston Grant by placing a collection jar in our lobby if asked to do so.
*We agree that our practice name and doctor's names maybe used in Press Releases created to promote the Boydston Grant, Animal Health Foundation, and SCVMA

Question Title

* 1. YOUR information

Hospital Name

Medical Director (DVM)

Email for DVM above

Cell phone for DVM above

Primary Contact Person Name

Email for Primary Contact Person above

Cell phone for Primary Contact Person above

Hospital address Street

Hospital address City

Hospital address Zip Code

Names of SCVMA DVM(s) on staff

Question Title

* 2. I certify that all of the following have been answered truthfully and accurately.

Hospital Director

Hospital Contact Person

Date