Application for Coco’s Eye Care Grant

    Owner Details

    Contact Name (required)

    Your Email (required)

    Phone (required)

    Shipping Address

    How did you hear about Second Chances For Blind Dogs?

    Dog's Details

    • Dog's Name

    • Dog's Age

    • Dog's Breed

    • Dog's Weight (lbs)


    Upload Photos Of Your Blind Dog:

    We may post the pictures on Second Chances For Blind Dogs' website and/or Facebook page.

      IMPORTANT!!! Images over (12mb) or (12,000kb) each will have to be re-sized in order to upload.

      If you are having a problem uploading photos, please crop them and resave them to make file smaller. Refresh computer and try again. If you still have issues, please text 818.943.9673 or send email to
      We will help you 🙂

    • Photo Of Your Dog

    • Upload Vet bill/Estimate

    Animal Model Release Form

    I, , (Name of Pet Owner on behalf of Animal Model) hereby irrevocably authorize Silvie Bordeaux with Second Chances For Blind Dogs "SCFBD" and its affiliates subsidiaries, divisions, agents, representatives, producers, reporters, employees, successors and assigns to copyright, publish, reproduce, exhibit, transmit, broadcast, televise, digitize, display, otherwise use, and permit others to use, (a) my and pet’s name, image, likeness, and voice, and (b) all photographs, recordings, videotapes, audiovisual materials, any biographical material which I may provide, writings, statements and quotations of my pet or of myself (collectively, the “Materials”), in any manner, form, or format whatsoever now or hereinafter created, including on the internet, and for any purpose, including, but not limited to, all worldwide media, an unlimited number of times in perpetuity and in the promotion, advertising, sale, publicizing and promotion of Silvie Bordeaux with Second Chances For Blind Dogs "SCFBD" and all its affiliates, without further consent from or compensation to me.

    I hereby waive any right of inspection or approval of my appearance or the uses to which such appearance may be put and hereby agree not to assert any and all manner of liabilities, claims and demands of any kind or nature, whatsoever, in law or equity, against anyone relating to the exercise of the permissions granted hereunder.

    I further represent that any statements made by me during my appearance are true, to the best of my knowledge, and that neither they nor my appearance will violate or infringe upon the rights of any third party.

    Pet Owner name:

    Name of Pet:


    • Country:

    • City:

    • State:

    • ZipCode:


    Your Email (required)

    Veterinarian Name:

    Veterinarian Number:

    How Much Is Expected Expense?