Canine Assistance Request Form

Canine Assistance Request Profile
Our Companions Animal Rescue is a 501c3 non-profit organization. The mission of Our Companions is to offer programs and services that support and nurture a positive relationship between people and their pets. Our Companions Community Canine Behavior Programs are specifically designed with the bond between people and their pets in mind.

Please complete this form to help us understand you, your dog, and any specific goals you have within our programs.

If you are unsure if you are eligible for this program or require additional assistance, please do not hesitate to contact us at 860-242-9999 or Helpline@OurCompanions.org

All forms will be reviewed within 5 to 10 business days. Pet guardians will be contacted if additional information is required or if there is a concern regarding program selection and/or availability prior to scheduling.

Please be patient, as we are experiencing a higher level case load than normal. We are NOT able to offer immediate placement or crisis assistance at this time.
Client Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am completing this paperwork for:*

Behavior Evalution/ConsultationRehoming ProgramAdoption Follow UpGSRNE Assessment
Why would you like to rehome this dog?*
Skip if not applicable.
Please describe in your own words your primary reason for this consultation.*
Skip if not applicable.

Household Information
How many people live in your house?*
Please list the names, ages, and relationship of everyone in the home.*
Example: "John, 46, Husband" or "Sally, 11, Daughter"
Does your dog live with other animals?*

No other animalsDogsCatsOther
Please list the names, age, and species/breed of all other animals in the home.*
Example: "Buddy, 6, Lab Mix" or "Holly, 3, Indoor Cat"
Please describe how your dog behaves with the other animals in the home.*

Adoption Follow-Up Survey
Dog's Name*
Dog's Previous Name (if changed)
What program was this dog adopted from?*

SanctuaryRehoming
Please provide a brief summary of how the settle-in period has been going and what you would like to cover during your Adoption Follow-Up Meeting. *

Rabies Vaccination Agreement
Every dog participating in training programs at Our Companions Animal Rescue (OCAR) must be up-to-date on their Rabies Vaccination in accordance with Connecticut State Law. All clients are required to submit proof of vaccination before the first session.
Is your dog currently Up-to-Date on their Rabies Vaccination?*

YesNo
If yes, what is the expiration date? *

Photo Release
Photos and videos are often taken of participants and their dogs during training programs at Our Companions Animal Rescue and are often used in our social media posts, newsletters, promotional materials, websites, etc. It is important to us that we respect the safety, security, and personal rights of all of our community members.

Yes, I grant permission for OCAR to take photos/videos of myself, my pet(s), and property to use and publish these materials in both print and electronic media.No, I do NOT grant permission for OCAR to take photos/videos of myself, my pet(s), and property to use and publish these materials in both print and electronic media
Signature*

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Print Name*
Date*

MonthDayYear

Agreement to Hold Harmless
In consideration for participation in the training offered by Our Companions Animal Rescue (OCAR), I hereby assume all responsibility for any claim, loss or damage, of whatever kind or nature, whether to person or property, arising out of or related to this training. I further agree that I will hold OCAR, its officers, directors, trainers, volunteers, agents and members harmless and defend them from any and all liability for any injury, claim, damage or loss, of whatever kind or nature, whether to person or property, arising out of or related to this training. I agree to indemnify OCAR, its officers, directors, trainers, volunteers, agents or members who might be the subject of any claim, suit, loss or damage caused in any way by any act or negligence on my part or on the part of my dog during the Training Program.

I acknowledge that while OCAR may facilitate and sanction this training, OCAR does not have and does not exercise control of the conduct of my dog(s). I further recognize that OCAR is providing this training as a community service and utilizes volunteer trainers with varying levels of training experience. I also understand that the degree to which a dog is successfully trained is a function of the interest, commitment, and cooperation of the owner. I acknowledge and agree that there is no guarantee that my dog will achieve the desired level of training, despite the best efforts of the instructor. I also acknowledge that all information I have provided is factual, complete, and honest.
Signature*

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Print Name*
Date*

MonthDayYear

Additional Notes, Photos, & Records
Please include any additional notes you believe will help us understand the needs of you and your dog and how we may best help you in our programs.
OPTIONAL: File Upload.

Save time by submitting your vaccination records, vet records, and photos directly to this form. You can also email submissions to Edie@Ourcompanions.org. Please note, rehoming and behavior evaluation appointments will NOT be scheduled without a copy of up-to-date vet records.
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Canine Assistance Request Profile

Client Information

Dog Information

Household Information

Daily Life

Medical History

Behavioral History

Fear & Aggression

Adoption Follow-Up Survey

Rabies Vaccination Agreement

Photo Release

Agreement to Hold Harmless

Additional Notes, Photos, & Records