On Going Care Application

Anyone who has made a serious commitment to the sport of dogs for at least five years and is suffering from a life-threatening or terminal illness qualifies for assistance from Take The Lead.

An application may be obtained by calling us at 1-800-814-1123 or by writing us at:

Take The Lead, 215 Washington Street, Suite 110, Watertown, NY 13601

Applications can also be submitted on-line by following the Apply for Assistance Link above. You can apply for yourself or for a friend and be assured that all calls and correspondence are strictly confidential.

Please fill in as many fields as possible and click the NEXT button at the bottom of the page. Once you have completed each form section click the SUBMIT button. All information is confidential and will be used for Take The Lead purposes only.

(Note that information entered into this form is protected by a secure Internet connection using 128 bit encryption to protect the privacy and security of your information.)

INVOLVEMENT

MEDICAL

EMPLOYMENT

HOUSEHOLD

I certify that the above information is true and correct. I understand the following:

* The information is being given in connection with services provided by Take The Lead, Inc.

* The Take The Lead Assistance Administration Committee may verify the information given on this form.

* If I deliberately misrepresent information on this application, I agree to repay benefits provided by Take The Lead, Inc. and I may be prosecuted under the applicable State and Federal statutes.

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