Hope & Heroes Rescue Program Application

Applicant's Full Name*

First and last name

Contact Phone*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant’s Date of Birth*

Date

Applicant’s Age*

Please note that a C4C trainer will be contacting you to set up a time to do an interview in person or virtual (zoom). This interview is mostly to understand your lifestyle, where you live, your activity level, more about you, etc. Please note that this application is for a COMPANION DOG. Please ensure that this application is filled out to the best of your ability. Any missing information may cause a delay in finding and receiving a companion dog.

List all family members/friends who live with you, the applicant or spend a significant amount of time in your home on a daily or regular basis:*

Are you or anyone you live with allergic to dogs?*

YesNo

Are you or anyone you live with afraid of dogs?*

YesNo

Do you have a job or are retired:*

YesRetiredNo job and not retired

Where do you work?

What days? In person/virtual?

Where did you retire from?

Are there any other animals in the home?*

YesNo

Type and ages:*

Are the animals (specifically dogs) in your home fixed/neutered?*

YesNo

Once a dog is placed with the applicant, he/she has the responsibility of caring for their companion dog (pet). This requires a financial commitment to the dog’s health and well being. Are you able to feed and care for your dog including but not limited to, food, monthly preventative and veterinary care?*

YesNo - however I live with a trusted adult that will be taking care of the dog DAILY.No and I do not live with a trusted adult.

Trusted Adult’s Name:

Additional training sessions, training tools, etc. may be required and would be the cost of the recipient. Are these extra costs you are prepared to possibly incur?*

YesNo

Do you have any medical conditions?*

YesNo

Please list medical condiations

Do you have any mental health diagnoses?*

YesNo

Please list any mental health diagnoses?

Do you take any medication for mental health diagnoses?*

YesNo

Do these diagnoses/medications impact your life in any way?*

YesNo

Please explain how they impact you.

Would any of your medical conditions, mental health diagnoses or anything related to your physical/mental health impact your ability to take care of a companion dog?*

YesNo

If yes, what help would you need? Also, do you have a family member that will assist with taking care of the companion dog?

Reason/s why you believe you could benefit from a companion dog:

When applying for a companion dog, you have the option to pay for the initial training, and care of the dog while it is at the Canines for Change Facility. If you do not pay for the training/care then we need a business sponsor to help with this cost. The cost is $2,500.*

I can personally pay $2,500 for the initial training and care of my companion dog before they are placed with me.I cannot personally pay $2,500 for the initial training and care of my companion dog, I can pay part and have talked to this business/person and they would like to pay for the remaining balance for me.I cannot personally pay $2,500 for the initial training and care of my companion dog, I would like to be added to a sponsor list that is sent out to businesses that sponsor these dogs. *Please note that this takes a bit longer than the previous options.

Business/Family Name:

A companion dog has been rescued from a shelter/non profit locally and is matched with their “person”. Do you understand that Canines for Change and any organization working with Canines for Change are not liable for any unknown medical conditions that may come up in the lifetime of the companion dog?*

Yes, I understandNo, I do not understand

Disclaimer:

A completed application does not guarantee a companion dog through Canines for Change. Canines for Change and any organization working with Canines for Change, reserves the right to deny any applicant for a companion dog for any reason.

Signature:*

Date:*

Date

Hope & Heroes Rescue Program Application

Household Information & Dog Care