Community Outreach Request Form DRAFT Community Outreach Application OLD Use this form to request short term assistance through SAFE's Community Outreach program. If you are unable to complete this online application, you may download a printed version at the link above and mail it to us. You are aware that SAFE is located in the state of Washington, USA, and is only able to help horses and horse owners in WA state?*Yes, I am located in WA stateNo, I am located outside SAFE's region.If you are located outside SAFE's area, you will need to contact a rescue organization closer in your area. A list of rescue organizations who may be able to help you is located at https://homesforhorses.org/members/Name First Last PhoneEmail Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is this address where the horse(s) are located?YesNoBoarding Facility Name (if applicable)Address where horse(s) are located Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Property Owner's Name (if different from yours) First Last Property Owner's Phone Number (if different from yours)How many horses do you currently own?OneTwoThreeFour or MoreIf you own more than three horses, how many horses do you own in total?*Horse 1Horse 1 NameHorse 1 Age (or Date/Year of Birth)Horse 1 SexMare or FillyStallion or ColtGeldingHorse 1 BreedHorse 1 Physical ConditionExcellentGoodFairPoorIf horse's condition is Fair or Poor, please provide details.Horse 2Horse 2 NameHorse 2 Age (or Date/Year of Birth)Horse 2 SexMare or FillyStallion or ColtGeldingHorse 2 BreedHorse 2 Physical ConditionExcellentGoodFairPoorIf Horse 2's condition is Fair or Poor, please provide details.Horse 3Horse 3 NameHorse 3 Age (or Date/Year of Birth)Horse 3 SexMare or FillyStallion or ColtGeldingHorse 3 BreedHorse 3 Physical ConditionExcellentGoodFairPoorIf Horse 3's condition is Fair or Poor, please provide details.Additional HorsesProvide information on each horse you own, including age, sex, breed, condition, and details if condition is Fair or Poor:*Short Term AssistanceWhat type of assistance are you seeking?* Hay and/or Grain Farrier Care Veterinary Care Gelding Assistance Euthanasia Assistance Other I wish to surrender my horse(s) to SAFE Hay and/or GrainHow many months of assistance are you requesting?One MonthThree MonthsApproximately how much hay do you have on hand right now?NoneOne bale or less2-3 bales4-5 balesIf your application is approved, SAFE will contact your local feed store and purchase a quantity of hay for you. You will need to pick up this hay and transport it to your property. Which feed stores in your area are convenient for you?Farrier CareHow many months of assistance are you requesting?One MonthThree MonthsDate of last farrier workName and phone number of your regular farrierVet CareWho is your regular vet?Is your horse up to date on teeth and vaccinations?Type of vet care needed (please be as specific as possible)Gelding AssistanceIs there a vet you would prefer to use?Has your colt or stallion received a tetanus shot and/or booster?Yes, bothYes, but no boosterNoDate of last tetanus shot/boosterIs your colt or stallion halter trained?YesNoAre you able to perform the required post-surgery forced exercise?(10-15 minutes of trotting, twice a day, for two weeks)YesNoDon't knowEuthanasia/Serenity FundBriefly describe your horse's situation or condition.Who is your regular vet?OtherWhat type of assistance are you looking for?Surrendering a horse to SAFESAFE is a rescue organization with a mission to help horses facing neglect, abuse, or starvation. When reviewing intake requests, we start by evaluating risk factors to the horse(s) we are being asked to take. The limited number of spaces in our rescue program are reserved for neglected or abused horses, or horses at risk of neglect when their owner truly has no other options to care for them. You are fully aware that SAFE is a nonprofit rescue organization that focuses its limited resources on horses facing neglect, abuse, or starvation?*YesNoIf SAFE was to take your horse, one requirement of our surrender agreement is that you do not obtain another horse for at least one year. Is that acceptable to you?*YesNoPlease provide as much information as you can as to why you can no longer keep your horse(s) and why you are unable to find new homes on your own:*How long have you needed to rehome the horse?What steps have you taken to try to safely rehome your horse yourself?*Is there a date by which the horse needs to be gone? If yes, what is that date?*Is your horse:Rideable, well trainedRideable, with issuesNon-RideableUnstartedUntouchableUnknownAny known health issues?Any known behavioral issues?Statement of NeedAnnual Household IncomeReason(s) for seeking financial assistanceAction PlanBefore we grant temporary assistance, we need your assurance that there is a plan in place to improve your situation for the welfare of your horse(s). If you're able to share your thoughts on this plan as part of this application, that would be very helpful to us as we consider your request for assistance. We may ask you to provide more detailed information about your action plan as part of the decision making process.Please describe your plan to either: (1) become financially capable of supporting your horses; OR (2) to responsibly rehome your horses within three months.Next StepsA representative from SAFE will be in contact with you in 1-3 business days. If you need immediate assistance, please email firstname.lastname@example.orgPreferred method of communciation Email Phone Best time to reach you by phone Weekdays -- Morning Weekdays -- Afternoon Weekdays -- Evening Weekends -- Morning Weekends -- Afternoon Weekends -- Evening Anything else you'd like to add?