Application

Veteran Companion Animal Services Client Application

Thank you for you interest in adopting a dog through VCAS. Please fill out this application as thoroughly as possible. Your responses will help us find that best dog for you and/or your family. If you have any questions, please contact us at veterancompanion@gmail.com.

Applicant Information
First Name
M.I.
Last Name
Street Address
Apartment/Unit #
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Marital Status
ex. single, divorced, widowed, married

Emergency Contact
First Name
M.I.
Last Name
Street Address
Apartment/Unit #
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-mail

Employment
Are you currently employed?


If no, date of last employment


What is your trade?
Military Experience
Are you a military Veteran?
Are you currently in the Armed Forces?
Applicant is a family member of active military member or lost to service member
If yes, please select status of family member


If a family member, relationship to service member
ex. daughter, son, spouse, father


Service branch of applicant or family member
ex. Marine Corps, Army, Navy, Air Force


Start date of military service


End date of military service (active and reserve) - If currently active or reserve, leave blank


MOS, MOSC, NEC or AFSC code


Type of discharge - If currently active, leave blank

Household Information
Where do you live?
If you rent your residence (home or apartment), are you able to own pets as part of your lease?


If yes, what is the pet policy for your rental? Please copy and paste the policy from your lease/pet addendum:
If there is a pet deposit and/or monthly fee, do you have the funds to cover it?
No file selected
No file selected


Enter all members of the household (Name, age, relationship to you *Note: Include children)
ex. John Smith, 19, son
Is anyone in the household allergic to dogs?
Do you have any other attendants visiting the home?


If other, please provide details


How often do they visit the home?
ex. daily, weekly


If you were hospitalized, is there someone who can care for your dog?


If yes, provide name


Do you have other pets within the household?


If yes, please provide details
ex. 7 year old golden retriever and a cat (age and breed unknown)
Have you ever had to re-home a pet? (give your pet to another home or shelter because you could not care for it)


If yes, please provide reason
Your living situation has (check all that apply)

Activities
Do you have any issues with mobility?


If yes, please describe any problems with walking, carrying items, exercising, performing household chores/duties, grocery shopping, engagement in activities outside of the home or self-care.
Do you currently use any assistive devices?
If yes, please specify which type


If other, please provide details


If using more than one assistive device, please name your primary device (the device you use the most)


Can you handle a dog with a leash without assistance?


If no, what assistance would you need?

Goals
What benefits do you anticipate having by adopting a dog?
Are you interested in increasing your social and/or outdoor activities once you receive the dog?
If you received a dog through VCAS, would you be taking the dog to a shooting range or other location where loud noises are common? (we ask this to be sure that we find the right dog for your needs)

Animal Questionnaire
Have you ever owned a dog before?

Please choose how confident you feel in the following areas of dog care:


Is there a particular breed of dog you like?
*Note: VCAS cannot guarantee a particular breed and a particular breed may not fit your lifestyle


Which of the following characteristics best describes your preferred dog?
Choose 6

Additional Information
Please provide any additional information that would be important and helpful for Veteran Companion Animal Services to know.
If a dog is placed with you through VCAS, would you be OK with the media covering some of the story?
Would you mind talking to the media about how your dog impacts your life?
If approved for a dog, would you allow VCAS to run a background check?
I read the “General Care & Responsibilities of Owning a Dog” document and understand the responsibilities involved in owning a dog.

Liability Release

If approved for a dog, Veteran Companion Animal Services (VCAS) will require that you sign a release of liability document.


Signature

By signing this document, I attest that all of the information I have provided in this application is true and correct. I understand that filling out an application does not guarantee me a dog. I understand that if I do adopt through Veteran Companion Animal Services (VCAS) I will sign a contract and this application will become a part of that contract. I understand that the dog can be reclaimed if any information in this application is found to be false and the adoption contract will be considered null and void.

*Non-discrimination Statement: Veteran Companion Animal Services does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.


Signature
*Note: By entering your name you are signing this application


Date



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Once application is completed, click "Send" below to submit.



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