Leg Up Program Application - Colorado Horse Rescue

General Information

This program provides short-term financial aid to owners in difficult, temporary financial situations.

Date*

Owner Name*

First Last

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone Number*

Email*

Does your horse live at this same address?

Yes
No

If not, please provide the address of the horse's location:

Name of Facility Street Address City State / Province / Region ZIP / Postal Code

Primary Contact/Caregiver for Facility, If Applicable

First Last

Caregiver Phone Number, If Applicable

Why are you seeking assistance for your horse?*

How do you plan to resolve your situation?*

What areas of equine care do you need the MOST URGENT assistance with?*

How long do you foresee needing assistance to care for your horse?*

Your Horse's Information

Horse Name*

First

Breed*

Gender*

Date Foaled/Age*

Notable markings, scars, etc.*

Who is your veterinary provider (name of individual or business)?*

Veterinarian Phone Number*

Most recent vet call date:

What type of care was provided?

Does your horse have any previously diagnosed health issues that are not already listed on this form (lameness, respiratory disease, etc)? How are these being actively treated or managed?

Who is your farrier care provider?*

First Last

Farrier Phone Number*

Most recent hoof care appointment date:

Describe what you feed your horse on a daily basis.*

Is there any other information you would like to provide?

Signature

By signing this application, I certify that: I am over the age of 18 and I currently possess a brand inspection for this horse; I have disclosed all information requested for this horse; I give Colorado Horse Rescue permission to contact the veterinarian and farrier listed on this application to obtain records and receive consultation in regards to this horse; all information contained in this application is truthful to the best of my knowledge.

Signature*

Upload an Image of Your Horse(s)*

This is required for CHR's grant reporting and program funding, max file size 64MB. (allowed file types: jpg, png, pdf, gif)

Name

This field is for validation purposes and should be left unchanged.