Take the Lead -Application for Assistance

Name
Address
City, State, Zip
County
Phone (Home)
Phone (Work)
Email Address
Social Security #
Date of Birth

INVOLVEMENT IN THE SPORT OF DOGS:

Do you currently own AKC registered dogs?	Yes No
If so, how many?
What breeds?
Are you currently active in the sport?	Yes No
If not, please state why
Number of years of active involvement
Are you, or have you been a breeder?	Yes No
What breeds?
Are you, or have you been an exhibitor?	Yes No
What breeds?
Conformation, obedience, field trials?
What breeds?
Are you, or have you been a professional handler?	Yes No
What Breeds?
Are you, or have you been an AKC judge?	Yes No
How many years?
Are you, or have you been a member of a member or licensed kennel club?	Yes No
If yes, which one(s)?
Please list 5 shows, with dates, where you have exhibited or judged in the last 4 years

Any other involvement in the sport of dogs? Please specify

REFERENCES:
List information of 2 people in the sport (club member, judge, handler, superintendent, etc.)
References will be contacted only if necessary to verify your participation in the sport.

REFERENCE #1
Name
Address
City, State, Zip
Phone

REFERENCE #2
Name
Address
City, State, Zip
Phone

MEDICAL SITUATION & ASSISTANCE: Describe your medical situation in detail. Also, please mail or fax a letter from your physician with your diagnosis and prognosis. This letter should be dated within 30 days of its submission.

Take the Lead provides assistance by making direct payment to providers for services such as medication, insurance premiums, rent, utilities, transportation to doctors or hospitals and other related services. Please be specific as to what your needs are and what the approximate cost is per month. Where possible list name provider and type and cost of services provided.


Primary Physician
Address
City, State, Zip
Phone
Fax

PLEASE SUBMIT A CURRENT LETTER FROM YOUR PHYSICIAN WITH DIAGNOSIS, PROGNOSIS AND TREATMENT PLAN.

COVERAGE:

Have you applied for Medicaid	Yes No
If Yes, your status	Approved Denied Pending
Medicaid Number

HEALTH INSURANCE INFO/MEDICAL CARE COVERAGE:

Do you have health insurance, retirement, HMO or another plan that plays for your medical care?

	Private Insurance (not HMO)
	Self-Pay
	Health Maintenance Org. (HMO)
	Medicare
	None
Other Public Program
	Uninsured or Unable to pay
Company Name
Company Address
City, State, Zip
Subscriber's Name
Group Policy #
Your Policy #

EMPLOYMENT STATUS:

Full Time (35+ hrs per wk)
Part Time (-35 hrs per wk)
Not employed & not disabled
Medically unable to work

TOTAL ASSETS:

PLEASE INCLUDE A COPY OF LAST YEARS TAX RETURN (1040)

Present ANNUAL GROSS INCOME
(Documentation may be required)

Salary/Wages
Self
Spouse/Significant Other
Interest/Dividends
Benefits	Please list sources (i.e.: public assistance, unemployment, etc.)
Disability	Please list sources (i.e.: social security, workers compensation, etc.)
Other Income	Please explain

LIVING ARRANGEMENTS:

	Own Rent
Mortgage/Rent Amt
Payable to
City, State, Zip
Phone
Monthly Utility Cost

HOUSEHOLD MEMBERS:

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:

Alternate Contact Person - Optional

I authorize Take the Lead, Inc. to speak with the following persons about my application if you are unable to contact me (i.e., Social Worker, Lawyer, Family Member or Friend)

Name:
Relationship:
Phone:

CERTIFICATION STATEMENT:

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.

I AGREE DATE