CLIENT APPLICATION FORM

CLIENT APPLICATION FORM
Thank you so much for being connecting with us!!

We encourage referrals from authorised sources such as local vets, doctors, social workers, ACAT representatives and hospitals.

If you do not have a referral from one of these services, that is still ok! Please submit the form below and someone will contact you for further information.

So, let’s begin!
Where did you hear about us?*
Full Name*

First NameLast Name
Client Email
example@example.com
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to client (if you are filling this out for yourself, just pop in "self")*
Services you could use some help with
Tick all that apply:*

WalkingTransportFeeding/medicaionsCompanionshipOther
How long will you require our support?

Short Term (less than 6 months)Ongoing
Tell us about your pet(s)*
How many need assistance?
How many walks per week are desired?
Name of Pet(s)
Breed(s)
Age(s)
Is your pet desexed?*

YesNo
How good are they with other animals? Kids?
Helps match an appropriate volunteer
Photo - We LOVE seeing photos of your pet!! Helps us match a volunteer much faster if they fall in love with your pooch :)

Cancelof
Referral Information (if applicable)

We encourage referrals from people in the community who might be looking out for an elderly person in need.

We would love your information should we need further information or have trouble connecting with the person referred.
Name of referring person
Organisation
Referrer Contact number
If more information is required
Email
Referral letter (if applicable)

Cancelof
All done!

Your application will be processed in 1-2 weeks. We are likely to call you for some further information also.

The information you provide on this application will be used solely for the consideration of your suitability as a client with Paws for Connection.

Thank you and chat soon!
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