Facility Dog Application. (To be completed by person to handle & house facility dog)
|
|
- Cody Kelley
- 5 years ago
- Views:
Transcription
1 Facility Dog Application (To be completed by person to handle & house facility dog) of application / / Name of applicant Street address Mailing address (if different than above) City State ZIP code address Home phone ( ) - Cell phone ( ) - Other phone ( ) - Alternative contact in case we can t reach you ( ) - Relationship to the alternative contact listed Gender: Male Female of Birth / / Age Have you applied to any other program for a facility dog? Yes No Do you consider yourself: (Circle one) Active Very Active Inactive What are your hobbies/regular activities? Are there specific places you visit regularly that a dog should be comfortable with such as physical therapy, public transportation, school/university etc? Are there medical considerations that may affect how you interact/handle a dog? Yes No P a g e 1
2 Do you have any disabilities: (Please check all that apply) Speech Hearing Vision Impaired reaction speeds Learning (please indicate type) Mobility Information: (Please check all the apply) Walk Normally Walk slowly but steadily Walk Unsteadily Non-Ambulatory Wheelchair-Manual Wheelchair Power Crutches 1or2 Cane Walker Braces Right Handed Left Handed Do you have limits in arm or hand movement, please explain: Family/Living Situation What is your marital status? Single, never married Married Divorced Widowed Separated Have you ever been convicted of a felony? Yes No Are there currently any felony charges pending against you? Yes No Have you ever been invested for animal neglect or cruelty? Yes No If yes, explain: In what type of residence do you reside? Private home Apartment Dormitory Assisted Living Facility Group Home Mobile Home Other How long have you lived at your current residence? Do you plan to move in the next two years? Yes No If yes, please explain Do you live in a single story home? Yes No If no, is there an elevator/stair lift available for your use? Yes No Are there stairs going up to your residence? Yes No If yes, is there a ramp available for you? Yes No Do you have a fenced yard available for your use? Yes No Is there a pool in your yard? Yes No If yes, is the pool area fenced? Yes No P a g e 2
3 Do you live: Alone With spouse or significant other With parents With minor child(ren) Please list age(s) With grown child(ren) Please list age(s) With roommate(s) How many roommates share your home: Please list their age(s) and gender(s) M/F Age M/F Age M/F Age M/F Age With live-in caregiver Other (please specify) How many people live with you in your home Are there any other family members in your home with disabilities? Yes No Not applicable If yes, please specify Are you or anyone you live with allergic to dogs? Yes No If yes, explain Is anyone you live with afraid of or fear dogs? Yes No If yes, explain How many other pets do you live with Do you own these pets? Yes No Please indicate the type, age, and whether they live inside or outside for each pet: Have you ever owned a dog? Yes No What is your prior experience with dogs and their care? Are there traits that you like or dislike in dogs or certain type/breed of dogs? Facility dogs need daily care such as feeding, exercise, attention, and care. Please check all that you are willing to commit to and can provide: Veterinary Care Heartworm medicine Flea care Recommended Food Weekly grooming Ongoing training Emergency Care Exercise Ensure your dog behaves appropriately in public Being the person responsible for your dogs care and well being P a g e 3
4 Employment What is your current employment status? Employed, full time Employed, part time Unemployed Student (please specify level) How many months and/or years have you been with this employer? What is your job title/occupation? Are you exposed to paints, fumes or chemicals or other potential toxins on a regular basis while you work? Yes No If yes, please explain Is your work location stationary (office/desk job, classroom)? Yes No When not working with the facility dog, do you have a space at work where it can rest? Yes No Please explain Are you exposed to any loud noises on a regular basis on your job? Yes No If yes, please explain Acknowledgement and Signature I certify that all of the answers I have provided on this application are up to date, accurate and true to the best of my knowledge. I understand that completing an application does not guarantee acceptance as a Deafinitely Dogs! client, or placement of a service dog from Deafinitely Dogs! I understand and have included a $35.00 non-refundable application fee with my completed application. Signature of applicant Printed name of above P a g e 4
5 (Facility Information to be completed by facility supervisor) Name of facility Street address Mailing address (if different than above) City State ZIP code address Office phone ( ) - Cell phone ( ) - Other phone ( ) - Please describe your facility and the client population you serve: Explain the role or ways the proposed Handler for the facility dog is directly involved with your clients: Describe how you feel a facility dog will benefit your facility and the reasons for wanting one: P a g e 5
6 Describe a typical day at work for the proposed handler: Facility dogs need daily care such as feeding, exercise, attention, and care. Please check all that you are willing to commit to and can provide: Veterinary Care Heartworm medicine Flea care Recommended Food Weekly grooming Ongoing training Emergency Care Exercise Ensure your dog behaves appropriately in public Being the person responsible for your dog s care and well being We will arrange for a back-up handler to assist with the Facility Dog s care and handling in the event that the primary handler becomes unavailable: Yes No Name of backup facilitator I feel this facility would be able to use a Facility Dog from Deafinitley Dogs! effectively to accomplish work/client related goals. Supervisor Name (Printed) Supervisor Signature Supervisor Title P a g e 6
7 General Release of Liability Statement I hereby release any liability(ies) or claim(s) in participating in any activities or services sponsored by Deafinitely Dogs!, Inc. organization. I acknowledge that I assume the risks and responsibilities in such participation and hold Deafinitely Dogs!, Inc. harmless for any injuries or liabilities incurred or sustained in my participation. It is understood and agreed that, by acknowledging and signing this release, I irrevocably, unconditionally and completely releases and forever discharges Deafinitely Dogs!, Inc., and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents from any and all losses, demands, damages, obligations, liabilities, actions, causes of action, debts, suits, judgments and all claims of any kind or nature whether known or unknown, fixed or contingent, arising directly or indirectly from, as a result of or in connection with, or otherwise relating in any manner to any claims of liability, that were alleged, or could have been alleged, against Deafinitely Dogs!, Inc., and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents, that may in the future develop from or be caused directly or indirectly from any actions causing such liabilities. I acknowledge that I provide this release voluntarily and knowingly. Signature of Facility Supervisor Signature of Proposed Handler P a g e 7
8 Photo Release I understand and agree that the Deafinitely Dogs!, Inc. will be photographing applicants, student, students with dogs, graduates and volunteers during training and events for the purposes of providing community education and/ or promoting the program. This may include still photos and/or videography. I understand that there may occasionally be TV stations and/or news reporters who may be present at classes and events to take footage and/ or photos of students and dogs for training and/ or publicity purposes. I hereby grant Deafinitely Dogs!, Inc permission to use these photos or footage, and grant permission to newspapers or TV stations to use these photos or footage for training and/ or publicity purposes. I understand and agree that all photos taken by Deafinitely Dogs!, Inc. during the training are the exclusive property of Deafinitely Dogs!, Inc., and Deafinitely Dogs!, Inc. reserves the rights to all such photos or videography. Signature of applicant Signature of Proposed Handler P a g e 8
9 Fund Raising Facility Dogs are placed for free with each facility. There is a minimum donation of $7500. Deafinitely Dogs! is a 501 (c) (3) and donations are tax deductible. Please list at three clubs, churches, organizations, etc.. that you believe you would be willing to sponsor the cost (in total or in part) of a facility dog for your organization. 1. Organization Name Contacts First & Last Name Address Phone ( ) Organization Name Contacts First & Last Name Address Phone ( ) Organization Name Contacts First & Last Name Address Phone ( ) - Please note: If approved for a Facility Dog from Deafinitely Dogs! you will be given fundraising information and instructions. P a g e 9
10 Notes: P a g e 10
Dear Applicant: Sincerely, ICAN Client Services. Personal application form for a service dog Medical reference form Personal reference form
Dear Applicant: Thank you for your interest in applying for a service dog, through Indiana Canine Assistant Network, Inc. (ICAN). Entering into the process of applying for a service dog can be an emotional
More informationK9 CARE MONTANA, INC. SERVICE DOG APPLICATION FOR WOUNDED WARRIOR. Today's Date: Your Age: Your Sex: Name: (Mr./Mrs./Ms.): Address: City: State: Zip:
1 K9 CARE MONTANA, INC. SERVICE DOG APPLICATION FOR WOUNDED WARRIOR Today's Date: Your Age: Your Sex: Name: (Mr./Mrs./Ms.): Address: City: State: Zip: Daytime Phone: Evening Phone: Date of Birth: Height:
More informationWHERE TO SEND A COMPLETED APPLICATION
\ Dear Applicant: Thank you for your interest in applying for a service dog, through Indiana Canine Assistant Network, Inc. (ICAN). Entering into the process of applying for a service dog can be an emotional
More informationHypoglycemia Alert Dog Application
Hypoglycemia Alert Dog Application Contact Information Applicant Name Birth Date, Age Facilitator Name Relationship to applicant Birth Date (applicant under 18) Street Address City ST ZIP Code Home Phone
More informationAPPLICATION FOR HERO
APPLICATION FOR HERO Thank you for your interest in obtaining a service dog from Dogs Helping Heroes, Inc. ( DHH ). DHH provides trained service dogs to men and women disabled in the line of duty while
More informationValley of the Sun Dog Rescue Foster Family Application
Valley of the Sun Dog Rescue Foster Family Application Thank you for volunteering to share your home with a rescued dog. The information you provide on this application will help us make a better match
More informationService Dog Application
Thank you for requesting a service dog from the Dog Alliance. To qualify for a service dog under this program you need to have been discharged from the military with an honorable or medical discharge or
More informationK9 CARE MONTANA, INC. SERVICE DOG APPLICATION FOR AUTISM. Address: City: State: Zip: Daytime Phone: Evening Phone: Are you currently employed?
K9 CARE MONTANA, INC. SERVICE DOG APPLICATION FOR AUTISM Name of Parent/Caregiver: (Mr. /Mrs. /Ms.): Address: City: State: Zip: Daytime Phone: Evening Phone: Are you currently employed? Yes No Employer's
More informationADULT CLIENT APPLICATION AND MEDICAL HISTORY LOVING ANGEL SERVICE DOGS, INC. PLEASE PRINT CLEARLY
ADULT CLIENT APPLICATION AND MEDICAL HISTORY PLEASE PRINT CLEARLY GENERAL First Name Last Name Street Address City State Zip Home Phone Cell Phone (Including Area Code) E-Mail Date of birth (mm/dd/yyyy)
More informationSaint Francis Service Dogs Application for Service Dog
Saint Francis Service Dogs Application for Service Dog 1 ADOPTING A SAINT FRANCIS SERVICE DOG Saint Francis Service Dogs is a not for profit, community based corporation dedicated to increasing the independence
More informationHello! Sincerely, Cari Bishop Program Assistant
Hello! Thank you for your interest in applying for a Seizure Response Dog from Can Do Canines. We train assistance dogs to help clients maintain and increase their independence. Training is provided free
More informationService Dog Application Form
Wisconsin Academy for Graduate Service Dogs, Inc. 1337 Greenway Cross, #157 Madison, WI 53713 (608) 250-9247 Service Dog Application Form Instructions: Please complete and return the following items to
More informationService Dog Application
The Battle Buddy Foundation 8859 Cincinnati-Dayton Rd. Suite 202 West Chester, OH 45069 www.tbbf.org Service Dog Application A completed application must include the following: 1. The completed application
More informationApplication for: Service Dog Program
Application for: Service Dog Program Handi-Dogs, Inc. 75 S. Montego Drive Tucson AZ 85710 520-326-3412 service@handi-dogs.org All required forms must be returned before your consultation ($15) will be
More informationPower Paws Assistance Dogs
Power Paws Assistance Dogs 1201 N. 85 th Pl. Ste. B101~ Scottsdale, AZ 85257 Phone 480-970-1322 ~ Fax 480-947-3090 www.azpowerpaws.org PUPPY RAISER APPLICATION Name Puppy Name Address Puppy s Date of Birth
More informationDurant Animal Rescue Alliance
Durant Animal Rescue Alliance Adoption Application Adoption fees are $60-$65 dollars per completely vetted animal. Durant Animal Rescue Alliance reserves the right to change adoption fees and these fees
More informationValley of the Sun Dog Rescue Volunteer Application
Valley of the Sun Dog Rescue Volunteer Application Thank you for volunteering to share your time with a rescued dog. 1. Name and Date of Birth of the Volunteer : 2. Driver s License Number of Volunteer
More informationADOPTION APPLICATION
ADOPTION POLICY The Pet Adoption Center of Orange County (PAC-OC) seeks permanent, loving homes where our rescued dogs can live a long, happy and healthy life as part of a family. Adoptive families must
More informationCome Bye Border Collie Rescue P.O. Box 332 Highland, IL 62249
P.O. Box 332 Highland, IL 62249 At the time you submit your application, you will be reminded to pay the non-refundable application fee ($20 for dogs over 12 months and $30 for puppies under 12 months
More informationGerman Pinscher Club of America Rescue. (GPCA Rescue)
German Pinscher Club of America Rescue (GPCA Rescue) A d o p t i o n A g r e e m e n t & R e l e a s e S t a t e m e n t Our adoption agreement is designed with one purpose to protect the companion animal
More informationIn Home Service/ Hearing/ Companion Dog. In Home Service/ Hearing/ Companion Dog Questionnaire
In Home Service/ Hearing/ Companion Dog General Information An In Home service or hearing dog is a dog that is trained in specific service or hearing dog skills such that they can perform the skills in
More informationADOPTION POLICIES AND FEES PLEASE READ CAREFULLY BEFORE COMPLETING ADOPTION APPLICATION
Revised -- March 7, 2017 Page 1 ADOPTION POLICIES AND FEES PLEASE READ CAREFULLY BEFORE COMPLETING ADOPTION APPLICATION POLICIES : 1. Puppies and Kittens under 4 months of age will not be adopted into
More informationGREAT DANE RESCUE ALLIANCE, INC. Volunteer Application
GREAT DANE RESCUE ALLIANCE, INC. Volunteer Application Please Return to: Brittany Dail 3759 Countryaire Drive Ayden, NC 28513 Today's Date 1. Name 2. Email Address 3. Address 4. Phone # Cell Phone # Fax
More informationDog Adoption Application for
Dog Adoption Application for Reviewed by: Name: Home Phone: Spouse/Partner Name: Work Phone: Mailing Address: City/State/Zip: Street Address: City/State/Zip: How long there? Cell Phone: Drivers License/
More informationHAPPY TAILS DOG RESCUE, INC. CAT FOSTER WITH INTENT TO ADOPT APPLICATION
HAPPY TAILS DOG RESCUE, INC. CAT FOSTER WITH INTENT TO ADOPT APPLICATION DATE: NAME OF CAT YOU ARE INTERESTED IN FOSTERING WITH INTENT TO ADOPT: NAME: ADDRESS: TOWN/STATE/ZIP: EMAIL: HOME PHONE: CELL PHONE:
More informationPersonal Information Name Age Physical Address
Adoption Application Date: I am interested in adopting: Watson s Paws for the Cause Adoption Program watsonspawsforthecause@gmail.com Sponsored by Pet Medical Center www.animalhealing.net Phone: 509-545-4931
More informationApplicant #1: First Middle Last
Today s Date / / The Stafford SPCA s goal is to find permanent, loving, responsible homes for the animals in our care. We try to find a match that considers not only the best interests of the animal, but
More informationFlorida Cocker Spaniel Rescue - Foster Application
Florida Cocker Spaniel Rescue - Foster Application Thank you for wanting to help us in our mission of rescuing and re-homing cocker spaniels in Florida. Please understand that all cocker spaniels are different
More informationApplication For Adoption
Application For Adoption Thank you for your interest in rescuing a dog! Every CRCS dog comes with animal help, training tips, full access to our behavior specialist, and placement for the life of the dog.
More informationINDIVIDUAL RESCUER ADOPTION APPLICATION/CONTRACT INFORMATION
INDIVIDUAL RESCUER ADOPTION APPLICATION/CONTRACT INFORMATION Rescuer s Name: My goal is to place (insert pet s name) in a permanent, loving home. I RESERVE THE RIGHT TO DECLINE ANY APPLICATION. The adoption
More informationDOGS WITH WINGS ASSISTANCE DOG SOCIETY SERVICE DOG CHILD APPLICATION FORM. Child s Name: Date of Birth: Gender: Address:
PERSONAL INFORMATION DOGS WITH WINGS ASSISTANCE DOG SOCIETY SERVICE DOG CHILD APPLICATION FORM Date: Child s Name: Date of Birth: Gender: Child s medical diagnosis: Parent s Name: Parent s Name: Occupation:
More informationApplication Process for Veterans with Service Connected Disabilities
Application Process for Veterans with Service Connected Disabilities 1. We are currently only accepting applications from veterans who served during Desert Storm to present for fully certified Service
More informationNEW MEMBER APPLICATION
NEW MEMBER APPLICATION WEST NASHVILLE 5001 ALABAMA AVE. NASHVILLE, TN 37209 PHONE 615.334.0000 FAX 615.790.0475 TDSWEST@thedogspot.com www.thedogspot.com PARENT INFO Name(s): Address: City: State: Zip:
More informationADOPTION APPLICATION
Cockers Across PA Cocker Spaniel Rescue, Inc. ADOPTION APPLICATION Cockers Across PA Cocker Spaniel Rescue, Inc. (CAP) evaluates all applicants on a case by case basis and does not guarantee that all prospective
More informationSAINT BERNARD RESCUE FOUNDATION OREGON/WASHINGTON VOLUNTEER/FOSTER APPLICATION
SAINT BERNARD RESCUE FOUNDATION OREGON/WASHINGTON VOLUNTEER/FOSTER APPLICATION Please complete the following 4 page application and agreements and return to: Oregon Saint Bernard Rescue Allie Kane P.O.
More informationPaw Paw s Pets 3124 Broad Avenue Memphis, TN
Paw Paw s Pets 3124 Broad Avenue Memphis, TN 38112 901-286-5488 New Member Application Parent / Pet Owner Information Name(s): Address: City: State: Zip: Home Phone: Cell: Email: How did you hear about
More informationDear Parent, 1469 MARKET STREET, TALLAHASSEE, FL p: f: RESCUEMEFOUNDATION.US
Dear Parent, Thank you for downloading this brochure about our 2013 Animal Training Adventure summer camp. Our new summer program offers kids and teens the opportunity to learn basic animal obedience training
More informationDaycare & Boarding Application
New Daycare/Boarding Applicant Additional Family Member Existing Member s Updated Information Daycare & Boarding Application Guardian s/owner s Name: Address: City: State: Zip: Home Phone: ( ) Work Phone:
More informationPersonal Information. Name: Date of Birth:
ADOPTION APPLICATION At Adore-A-Bull Rescue, we get to know the traits and personalities of our dogs very well and try to make the best match between dog and pet parent. At times, we may determine that
More informationPLEASE KEEP THIS PAGE FOR YOUR RECORDS
General Information about All Pets Dog Daycare DOGS ALL dogs must pass a temperament test prior to their first day of daycare. Temperament tests generally last 1 hour and an appointment is REQUIRED for
More informationPLEASE PRINT CLEARLY! Name Date of Birth If younger than 18, parental approval is required. Home Address City State Zip
3910 Heron Drive Hood River, OR 97031 541-354-1083 FAX 877-833-7166 hoodriveradoptadog@gmail.com www.hoodriveradoptadog.org HOOD RIVER ADOPT Hood A River DOG Adopt VOLUNTEER A Dog APPLICATION Minimum VOLUNTEER
More informationBoarding/Daycare Contract
Boarding/Daycare Contract 1394 230th Street Glenwood City, Wisconsin 54013 715-265-9288 purrfectdog@live.com www.purrfectdog.com All boarding and daycare clients must sign a boarding/daycare contract for
More informationPET CARE AGREEMENT FOR DOG WALKING/IN-HOME PET VISITS. Client Name: Address: City, State, Zip: Out of town phone number (if applicable):
Date: FOUR LEGGED PET CARE PET CARE AGREEMENT FOR DOG WALKING/IN-HOME PET VISITS Client Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: E mail: Out of town phone number (if applicable):
More informationSymbiosis Service Dogs Symbiosis Service Dogs (hereinafter referred to as SSD ) Application Checklist
Symbiosis Service Dogs Symbiosis Service Dogs (hereinafter referred to as SSD ) Application Checklist Your application will be reviewed and an interview scheduled when all information has been received.
More informationTHE PURRING PARROT. Reservations, Deposit and Cancellation Policy
THE PURRING PARROT Client Information Owner s Name Date Address City State Zip Code Home Phone Cell Email Driver License Emergency Contact Phone Cell Phone Email Persons allowed to pick up and drop off
More informationHAPPY TAILS DOG RESCUE, INC. FOSTER WITH INTENT TO ADOPT APPLICATION
HAPPY TAILS DOG RESCUE, INC. FOSTER WITH INTENT TO ADOPT APPLICATION DATE: NAME OF DOG(S) YOU ARE INTERESTED IN FOSTERING WITH INTENT TO ADOPT: NAME: ADDRESS: TOWN/STATE/ZIP: EMAIL: HOME PHONE: CELL PHONE:
More informationwould like to introduce Fostering Explained
would like to introduce Fostering Explained Brisket! Hello, everybully! My name is Brisket, and let me be the first to say THANK YOU for considering foster care for one of my brudders or sisters! There
More informationMO PATRIOT PAWS APPLICATION. NAME: Date: CITY: STATE: ZIP (9 DIGITS): - I AM CURRENTLY: RETIRED DISCHARGED (TYPE): )
APPLICANT S PERSONAL INFORMATION MO PATRIOT PAWS APPLICATION NAME: Date: STREET ADDRESS: CITY: STATE: ZIP (9 DIGITS): - HOME PHONE: - - CELL PHONE: - - EMAIL: MARITAL STATUS: CHILDREN: YES NO AGES: I AM
More informationFOSTER APPLICATION: THANK YOU FOR YOUR INTEREST IN FOSTERING A BEAGLE THROUGH ARIZONA BEAGLE RESCUE AND HELPING TO SAVE A LIFE!
FOSTER APPLICATION: THANK YOU FOR YOUR INTEREST IN FOSTERING A BEAGLE THROUGH ARIZONA BEAGLE RESCUE AND HELPING TO SAVE A LIFE! FOSTER FAMILY INFORMATION: This form is for families interested in fostering.
More informationAdoption Application
Adopter Contact Information Co-Applicant (if applicable) Address City State ZIP Home Phone Your Work Phone Your Cell Phone Your Address Spouse s Address (if applicable) Your Occupation Spouse's Occupation
More informationMO PATRIOT PAWS APPLICATION. NAME: Date: CITY: STATE: ZIP (9 DIGITS): - I AM CURRENTLY: ACTIVE DUTY RETIRED DISCHARGED (TYPE: )
APPLICANT S PERSONAL INFORMATION MO PATRIOT PAWS APPLICATION NAME: Date: STREET ADDRESS: CITY: STATE: ZIP (9 DIGITS): - HOME PHONE: - - CELL PHONE: - - EMAIL: MARITAL STATUS: CHILDREN: YES NO AGES: I AM
More informationSteps to becoming an Animal House Volunteer
Steps to becoming an Animal House Volunteer Step #1 Fill out an application and hand in application fee: The application must be filled out entirely (this includes the liability waiver). Fees for individuals
More informationJuno Humane Inc Adoption Application Please to Mail to: PO 261 Hobe Sound Fl Phone:
Juno Humane Inc Adoption Application Please email to junohumane@gmail.com Mail to: PO 261 Hobe Sound Fl. 33455 Phone: 561-440-3640 Pet Name: Description: M/F: Microchip Number: *************************************************************************************
More informationBULVERDE AREA HUMANE SOCIETY P.O. BOX 50, BULVERDE, TEXAS
BULVERDE AREA HUMANE SOCIETY P.O. BOX 50, BULVERDE, TEXAS 78163 830-980-2247 Email: BAHShelter@yahoo.com www.bulverdeareahumanesociety.com Page 1 of 5 CAT ADOPTION APPLICATION/CONTRACT TERMS Date: How
More informationADOPTION APPLICATION
Thank you for your interest in adopting a Beagle through Arizona Beagle Rescue (AZBR). AZBR is a 501(c)(3), non-profit, no-kill, and all volunteer organization dedicated to Beagle rescue. We provide rescue,
More informationFoster Care Application
Foster Care Application 1000 Freedom Rd, Smithfield, NC 27577 919-437-5084 - blackdogclub@outlook.com Any field marked with an asterisk (*) denotes a required field! What pet(s) are you interested in fostering?
More informationOwner s Name. Address. Primary Phone Alternate Phone. . Security Word (used for pick up verification) Other person authorized to pick up dog
Paws n Claws Playcare 1530 W 26 th St. Erie PA 16508 814-456-7297 fax 814-456-7299 Playcare Pet Profile Owner s Name Address City St Zip Code Primary Phone Alternate Phone Email Security Word (used for
More informationAdoption Application/Contract
FOR STAFF USE ONLY Approved (Date) Initial Denied (Date) Initial Adoption Application/Contract *Incomplete applications will NOT be accepted. Those applications without veterinary and/or landlord contact
More informationDOG ADOPTION APPLICATION APPLICANT INFORMATION. Name: Age
APPLICANT INFORMATION Name: Age GSRNY places dogs in homes in the state of New York. Special cases may, in the sole discretion of GSRNY, be placed outside of the state. Address: City, State, Zip: E-Mail
More informationAGREEMENT & WAIVER FORM
AGREEMENT & WAIVER FORM By signing this document I, as the owner/agent/guardian, guarantee that I will be personally liable for all expenses resulting from daycare, boarding, bathing and grooming, veterinarian
More informationGerman Shepherd Rescue of New York, Inc. P.O.Box 242, Delmar, NY
DOG ADOPTION APPLICATION ************************* APPLICANT INFORMATION Name: Age GSRNY places dogs in homes in the state of New York, and in approved, special cases may, in the sole discretion of GSRNY,
More informationLITTLE TRAVERSE BAY HUMANE SOCIETY CAT ADOPTION POLICIES AND APPLICATION
For LTBHS Staff Use Only Date of Adoption: Animal Name: Adoption Price: Pd by Cash or Ck: Paid by Cr. Card: $ Cash Ck # MC V AX D DNA List Checked-Staff Initials: Staff Initials: CAT ADOPTION POLICIES
More informationPuppy Application. Referred by: Please check or circle answers not requiring written answers.
Puppy Application The following questions are being asked of you so that the right puppy and the right placement of each puppy can be made by bringing the various requirements of both the puppy and his
More informationClient Information. Doggie Information
Client Information Client (Person) Name: Emergency contact(s) & numbers: Street Address: City, State, Zip: Phone1: Phone2: Phone3: Email: Alternate contacts: Who is authorized to pick up/drop off your
More informationPET ADOPTION APPLICATION
Humane Society Western Region A -Kill, 501 (c) 3 n-profit Animal Rescue Organization Shelter Address: HappyPaws Farm, 19933 Old Burn Rd., Arlington, WA. Mailing Address: 8304 Wayne Ave, Stanwood, WA 98292
More informationAPPLICATION FOR EMOTIONAL SUPPORT DOG
APPLICATION FOR EMOTIONAL SUPPORT DOG PLEASE Save ont computer and TYPE or PRINT CLEARLY APPLICANT Information Name DOB: Email: Address: City: State: Zip: Phone: Work: Cell: Medical Diagnosis: Daily schedule:
More informationThe Humane Society of the Southeast, Inc.
The Humane Society of the Southeast, Inc. Preliminary Adoption Application for DOGS Thank you for your interest in adopting one of our wonderful rescue animals. Please complete the following information,
More informationDaycare/Overnight Boarding Master Record Enables us to provide the most comfortable & safe experience for your pet.
Daycare/Overnight Boarding Master Record Enables us to provide the most comfortable & safe experience for your pet. Rules and Regulations Trial Day/Date Monday Thursday (must be in at 7:00am) Health: All
More informationPENDER COUNTY HUMANE SOCIETY A No-Kill, Non-Profit Animal Rescue Organization Post Office Box 626, Burgaw, North Carolina (910)
PENDER COUNTY HUMANE SOCIETY A -Kill, n-profit Animal Rescue Organization Post Office Box 626, Burgaw, rth Carolina 28425 (910) 259-7022 ADOPTION AGREEMENT We ask that you give careful consideration to
More informationMember Application. Date: Member s Name. Address. City / State / Zip. Phone . Emergency Contact Name: Relation: Emergency Contact Phone:
Member Application Date: Member s Name Address City / State / Zip Phone Email Emergency Contact Name: Relation: Emergency Contact Phone: Membership Plan: Spa Fido Fitness Squash Full Facility All memberships
More informationLITTLE TRAVERSE BAY HUMANE SOCIETY CAT ADOPTION POLICIES AND APPLICATION
CAT ADOPTION POLICIES AND APPLICATION For LTBHS Staff Use Only Date of Adoption: Animal Name: Adoption Price: Pd by Cash or Ck: Paid by Cr. Card: Staff Initials: $ Cash Ck # MC V AX D 1. No animal will
More informationPLAY ALL DAY, LLC REGISTRATION FORM
Today s Date: How Did You Hear About Us? Owner(s) Name(s) Home Address City, State, Zip PLAY ALL DAY, LLC REGISTRATION FORM Start Date: OWNER INFORMATION Home Phone ( ) Work Phone ( ) Cell Phone ( ) Other
More informationDOG(S) I AM INTERESTED IN
SECOND CHANCE ANIMAL RESCUE WINDSOR-ESSEX ANIMAL ADOPTION APPLICATION DOG Second Chance Animal Rescue Windsor-Essex (SCAR) reserves the right to discard applications that have not been completed in full.
More informationVolunteer Application
Volunteer Application Name Birthdate Street Address Mailing Address Home Phone Email Address: Work Phone Cell Phone In case of emergency notify home phone work phone If currently employed, name of employer
More informationPersonal Information (to be completed by parent or guardian if under 18)
Preliminary Assistance and Service Dog Application Highland Canine Training, LLC 145 Foxfield Drive Harmony, NC 28634 www.highlandcanine.com 866.200.2207 Personal Information (to be completed by parent
More informationAGREEMENT & WAIVER FORM
AGREEMENT & WAIVER FORM By signing this document I, as the owner/agent/guardian, guarantee that I will be personally liable for all expenses resulting from daycare, boarding, bathing and grooming, veterinarian
More informationVOLUNTEER APPLICATION AND AGREEMENT
Big Cypress German Shepherd Rescue Naples Fl. 34120 Telephone: 239-777-0853 www.saveagermanshepherd.org Email Application To: adopt@saveagermanshepherd.org VOLUNTEER APPLICATION AND AGREEMENT Thank you
More informationVOLUNTEER QUESTIONAIRE
490 Didak Drive Arnprior, ON K7S 0C3 (613) 623-0916 VOLUNTEER QUESTIONAIRE Thank you for your interest in our volunteer program! We appreciate your interest in assisting the shelter be the best it can
More informationDOG ENROLLMENT FORM PET PARENT INFORMATION
DOG ENROLLMENT FORM Please complete the following questions to the best of your knowledge. This form and the subsequent evaluation are required before your dog can stay with us. This information will help
More informationJOYRIDES RESCUE ADOPTION APPLICATION/CONTRACT INFORMATION
JOYRIDES RESCUE ADOPTION APPLICATION/CONTRACT INFORMATION Our goal is to place pets in permanent, loving homes. Please complete this application so Joyrides Rescue may assist you in finding a special,
More informationDog Adoption Application Form
Dog Adoption Application Form If you are interested in adopting a dog or puppy, please fill out the form below. The questions in this application are in place to provide IWARS with the best information
More informationName. Address. City State Zip Code. Home Phone # Cell Phone # Work # Have you fostered before NO YES- for which organization?
True Friends Animal Welfare Center Foster Program The purpose of foster care is to allow a dog or cat to live in a home environment while awaiting permanent placement, permitting the foster family to evaluate
More informationSTANDARD SCHNAUZER CLUB of NORTHERN CALIFORNIA Adoption Application
STANDARD SCHNAUZER CLUB of RTHERN CALIFORNIA Adoption Application Date Received by SSCNC: Contact Information for You Name: Home Telephone: (Area Code + Seven) Best time to Call: Secondary Contact Telephone:
More informationPuppy Application. Relationship to Applicant Home Address City State Zip . Do you plan on showing this puppy?
Puppy Application Name of Applicant Age Name of Co-Applicant Age Relationship to Applicant Home Address City State Zip E-Mail Home Phone Work Phone Best time to contact Why do you want an Irish Terrier?
More informationPlease fill this form out completely and it to:
General Application rev 10/1/2015 Please fill this form out completely and email it to: info@northwestgermanshepherd.org Be sure to answer all questions as accurately as possible. Once your application
More informationThe Humane Society of Somerset County
The Humane Society of Somerset County P O Box 182, Somerset PA 15501 814-443-2121 www.somersetpets.com Adoption Process A successful adoption consists of finding a good home for our animals and a good
More informationFoster Application. Facebook.com/furrytailendingscaninerescue us at Susan Daniele, President
Foster Application Visit us at Facebook.com/furrytailendingscaninerescue Visit us at www.furrytailendingcaninerescue.org Susan Daniele, President Cell: (908) 507-0566 FAX: : (908) 847-0213 EMAIL: furrytailendings@embarqmail.com
More informationBOSTON TERRIER RESCUE CANADA
BOSTON TERRIER RESCUE CANADA Adoption Application How did you hear of Boston Terrier Rescue Canada (BTRC)? Date: Every BTRC rescue dog is vet examined, vaccinated, parasite tested and treated as required,
More informationMusic City Greyhound Adoption Foster Application
Music City Greyhound Adoption 1128 Neptune Road, Ashland City TN 37015 Music City Greyhound Adoption Foster Application Greyhound fostering is a serious responsibility and in most cases, at least a two
More informationDog Daycare Agreement
Happy Paws @ Unleashed 647 Lewiston Rd, Topsham ME 207-725-7990 www.unleashed-pets.com Dog Daycare Agreement Owner s Name: Address: City: State: Zip: Primary Phone: Alternate: Cell Phone: Alternate: Work
More informationPuppy Application. Referred by: If not referred to us, how did you hear about Genteel Standard Poodles?
Puppy Application The following questions are being asked of you so that the right puppy and the right placement of each puppy can be made by bringing the various requirements of both the puppy and his
More informationFinancial Aftercare Assistance Checklist
Financial Aftercare Assistance Checklist Please be sure all of the below items are included with your application If you already have a service dog: o Aftercare Assistance Application o Current Shot Records
More informationReservations, Deposit and Cancellation Policy
THE PURRING PARROT Client Information Owner s Name Date Address City State Zip Code Home Phone Cell Email Driver License Emergency Contact Phone Cell Phone Email Persons allowed to pick up and drop off
More informationRottweiler Hearts Rescue
Rottweiler Hearts Rescue 816 Wood Chapel Lane, Durham, NC 27703 Email: Volunteers@rottweilerheartsrescue.org Website: www.rottiehearts.org RHR Volunteer Application The RHR Volunteer Application is part
More informationSmall Paws-Big Hearts
Tiny Paws Small Dog Rescue *Adopted Pet Name: 2616 200 th Avenue Union Grove, Wisconsin 53182 Small Paws-Big Hearts Adoption Agreement for Cats I/We have adopted the animal(s) described below from Tiny
More informationPAWSITIVELY PERFECT BOARDING & DAYCARE AGREEMENT. Address: City: State: Zip: Phone: Home: Work: Cell: Text? Y N
PAWSITIVELY PERFECT BOARDING & DAYCARE AGREEMENT Contact Information: Owner s Name(s): Address: City: State: Zip: Phone: Home: Work: Cell: Text? Y N Email: Do you check your email while gone? Y N Emergency
More informationYes No PATIENT INFORMATION. Dogs: Cats: Feline Rabies: FVRCP (Feline Rhinotraceitis/Calicivirus/Panleukopenia):
NEW PATIENT & CLIENT INFORMATION SHEET CLIENT INFORMATION First name Last name Spouse/Partner first name Spouse/Partner last name Address City State Zip Primary Phone # (home work cell) CIRCLE ONE *Please
More informationCLASSIC GROOMING REGISTRATION POLICIES AND RELEASE FORM
CLASSIC GROOMING REGISTRATION POLICIES AND RELEASE FORM CLIENT INFORMATION Please tell us a bit about yourself Your Name First Last Partner/Spouse? His/Her Full Name Mailing Address Street Address Address
More informationDOG ADOPTION APPLICATION
DOG ADOPTION APPLICATION Name of Dog(s) you are applying for: Today s Date: Adoption Application Agreement PLEASE READ The speed at which your application is processed for adoption is dependent largely
More informationANIMAL RESCUE FOUNDATION of Louisiana
ADOPTION APPLICATION/CONTRACT PET S NAME Description NAME DATE ADDRESS CITY STATE ZIP PHONE (hm) (c) Your age EMAIL ADDRESS Would you like to receive ARF newsletters and updates? Yes No Welcome to ARFLA!
More information