Service/Companion Animal

Application for Service/Companion Animal

Name:

Address:

City:                                         State:                    Zip:

Phone:                                                                   Home or Mobile

Email:                                                                    Applicant or Veteran

Driver's License #:                                               State:                        Exp:

Is Veteran service-connected for PTSD or other condition? YES      NO  (if yes, explain)

 

 

What are your service-related, or other physical limitations?

 

 

Are you living alone?

Are you interested in, or have you met a specific dog at Valor?

Dog's Name:

Housing

Type of dwelling (house, apartment, etc.):

Owned or rented?

If renting, please provide landlord's name, address and phone number:

 

 

Are you allowed to have an animal?

If no, please explain reason for request:

 

**ESA dogs qualify under ADA for exemption in most cases of "No Pet" clauses**

Do you have a yard?

If yes, is it fenced?

Please describe yard:

 

If no yard, how will the service animal be exercised?

How long have you been at this dwelling?

If less than 2 years, give prior address:

 

Do you plan to move in the next 6mos. - 1 year?

If yes, explain:

 

Occupation:

Employer:

Work hours/days:

Employers name, address and phone:

 

 

Are there others living in home?

Spouse/housemate occupation:

Spouse/housemate employer:

Children in household?

Sex/ages of children:

 

 

Others living in the home/relationship to you:

 

 

 

Have all housemates agreed to have a service animal in the home?

If not, explain:

 

Will you be the primary caretaker of the service animal?

If not, who will be?

Does anyone living in the home have allergies?                         

If yes, to what?

Where will the service animal spend most of the day?

Where will the service animal spend most of the night?

How many hours will the service animal be left alone daily?

Are you willing to take service animal for obedience training?

If receiving an ESA, will you attend the training with your service animal?

Do you have other pets/animals?

List type/age/sex:

 

Are other animals spayed/neutered/vaccinated?

If there are dogs, have they been treated for heartworm?

Have you had pets before?

If so, where are they now?

Were previous pets spayed/neutered/vaccinated?

Do you have a Veterinarian?

If so, please give name, address and phone:

 

Have you considered costs, and will you be able to financially provide for regular medical care and maintenance of your service animal (spay/neutering, vaccinations/heartworm treatment, grooming, licensing, etc.), or in case of illness or emergency?

Have you adopted a pet in the past?

If so, when?

Number of pets you have had in the last 5 years:

Disposition of pets:

 

Agreement and Acceptance

I swear that, to the best of my knowledge, the above information is true and complete.

I agree my service animal will not be left outside. I will provide proper medical care, including spay/neuter by the date specified, and adequate food and water at all times. I will never mentally or physically abuse my pet. A dog will be walked on a leash at all times.

I understand that if for any reason I cannot keep this service animal, the animal MUST BE RETURNED to VALOR ONLY. There is no exception to this. If there is someone else who may be interested in this service animal, that person will be required to contact VALOR and be interviewed prior to placement.

By signing this agreement, I understand and accept the stipulations stated within. I further understand that VALOR reserves the right to accept or refuse any request for adoption of a service animal, at its own discretion, and that the decision is final.

I understand that the handling of animals could, at some point, put me in a dangerous position, and could result in injury to me or my personal property. On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless the VALOR CLINIC FOUNDATION and its directors, officers, employees and agents from any and all claims, causes of action, and demands of any nature, whether known or unknown, arising out of or in connection with my receipt of this service animal.

 

Signature: