SamUrgency Application for Funds

All Samoyed rescue groups qualify for SamUrgency funds. However, if you have access to other funding options such as through the National Samoyed Rescue organization, we request that you apply with them first. If additional funds are necessary, we invite you to apply to SamUrgency to help defray the difference.

Please fill out the form below completely. You will receive a confirmation within 48 hours that we have received your application.

If this is a life or death emergency and you need a response from us within 24 hours, email BOTH of these email addresses and include TWO phone numbers where you or another contact person can be reached.

Name:  
Address:  
City, State, Zip:  
Two phone numbers:  
Email address:  
Additional contact person:  
Name of Rescue Dog:  
Sex of dog:  
Neutered:  
Approximate age:  
Has the dog's breeder
(if known) been contacted: 		 
From where did you get
this rescue dog (shelter,
private owner, stray): 		 
Why was this dog given
to rescue: 		 
How long have you had
this dog in rescue: 		 
Has this dog shown any
aggressive behavior?
Please explain: 		 
Do you have a foster home
who will commit to keeping
this dog through his treatment
and recovery period? If yes,
who? 		 
Please provide a full
description of the rescue
dog's illness or injury,
including diagnosis: 		 
What is the course of
treatment: 		 
What is the dog's prognosis:  
Are there any other health
concerns or issues that would
make this dog not a good
candidate for adoption?
Please explain: 		 
Is this a life or death emergency?  
Where is the dog currently
(shelter, veterinarian,
boarding, foster home)? 		 
Name of Veterinarian clinic:  
Name of treating veterinarian:  
Address:  
City, State, Zip:  
Phone Number:  
Fax Number:  
Is this your regular rescue vet?  
How long have you used them?  
Will they give a rescue discount?  
Estimated cost of treatment:  
How much will your rescue
group be able to donate
towards this treatment? 		 
Are there any fund-raisers
being done to help this dog?
Please explain: 		 
How did you find out about
SamUrgency? 		 
Have you applied for funds
from SamUrgency before? When?		  
If funding is approved, I agree to abide by all rules and contingencies set forth by the SamUrgency board.

I understand that the SamUrgency board reviews this and all applications on a case-by-case basis, but funding comes from donators who will decide which dogs to donate to. I understand that if SamUrgency decides to approve this application, they can not guarantee that their generous donators will be able to totally pay for this dog's medical bills.

I understand that SamUrgency is a funding set up to help in emergency situations and can not pay for normal rescue expenses, such as neutering, vaccinations, grooming, long-term boarding or transportations costs.

Signature: