Medical Assistance Application

Our program provides financial assistance for dogs with life-threatening medical conditions. This program is only available to local residents who live in the Tri-Lakes Region of upstate NY, including Essex, Clinton and Franklin Counties.

In addition, you MUST show proof that you have applied for Care Credit at prior to sending in your application for our Medical/Financial Assistance program.

Please read all of the following before completing this application.

In order for your application to be reviewed and approved a copy of your pay stubs are required.
All of the above information must be completed in full.

You agree to inform The Joshua Fund of any other organization that is currently or in the future helping you financially with your pets medical needs. If you can get funding from other sources, The Joshua Fund reserves the right to pull our funding at that point.

You grant The Joshua Fund your express permission to discretely share as necessary the information you send us with other organizations, for the purpose of raising additional funds for your pet’s treatment.

Upon your signature of this application you are agreeing to network for The Joshua Fund whether it is for internet fund-raising widgets or sharing your story with other outlets such as Facebook or other media.

By signing this application you are granting The Joshua Fund the right to  use your pet’s photo and story for on-going fund-raising or in our publicity for “animals helped.”

At no point will The Joshua Fund divulge any of your personal financial information, address or phone number.

The Joshua Fund is not in any way responsible for the results of your pet’s treatment, the quality of your pet’s medical treatment or any treatment side effects. We will contact your Veterinarian to ask about the treatment plan and possible cost but we will not offer any opinion as to the medical treatment of your pet.

This agreement and waiver must be signed by the person(s) seeking funds in order to receive funds from The Joshua Fund. All recipients of The Joshua Fund funding and all applicants of The Joshua Fund funding agree that The Joshua Fund is in no way responsible for the outcome of any medical procedure funded in whole or in part by The Joshua Fund, nor is The Joshua Fund responsible for the outcome of funding being denied in whole or in part to the applicant(s).

Applicants for The Joshua Fund funding agree that The Joshua Fund will not be liable for any damages or losses as a result of either being denied funding or because of the outcome of any diagnosis or treatment funded in whole or in part by The Joshua Fund. The Joshua Fund and its employees do not make any representations or warranties, expressed or implied, regarding applications funding or awarding of funding, and are released and not liable for any costs, damages and expenses, including attorneys fees arising from any claims, damages, or liabilities asserted by third parties arising from application for or receipt of funds from The Joshua Fund.

Funding resources are limited and The Joshua Fund makes every effort to use limited funds in the most responsible way. The Joshua Fund does not discriminate on the basis of age, sex, or race. The Joshua Fund reserves the right to deny funding to anyone for any reason. Any monies collected via chip-ins or other means above and beyond  the needed funds of your pet’s medical needs will remain within the realm of The Joshua Fund to be used for other animals that are in need of medical care.

If you have any questions about our program, please ask before you submit this application. 

This is the entire contract, and no applicant for funding can modify it.

This contract is not assignable. Applicants for funding to The Joshua Fund waive all laws in conflict with the above agreement.

I understand the information above and I agree to this contract and waiver.

Please sign and date below. We will contact you within a reasonable period of time after receipt of this application.

Please complete this form in its entirety

First Name *
First Name
Home Phone
Home Phone
Cell Phone *
Cell Phone
Is your pet up to date on his/her vaccines?
Is your pet spayed or neutered?
Treating Veterinarian Information
Treating Veterinarian's Phone
Treating Veterinarian's Phone
Please enter N/A for those that do not apply
Income & Expense Breakdown / Monthly Expense Summary
Loan Payments (Include car loans, student loans and credit cards)
Have you applied for Care Credit at *
You must have applied for Care Credit before we can consider your application
Does your pet have health insurance?
Please Sign & Date
Date *
Date *