Companions for Heroes

Intake Form

Contact Information

First Name

Last Name

Phone (format: 555-555-5555)

Address 1

Address 2

City

State

Zip Code

Application Type

Are you applying for Companion Dog or Service Dog?

Have you ever been accepted or denied by another service dog organization/program?

Please explain your previous experience with a service dog organization/program?

Service Information

Branch of Service

Status

Rank

Years of Service

Military Discharge Category

Conflicts Served In

Public Service Area

Medical Information

Medical Diagnosis

Clinical Professional's Name or Supervisor's Name

Clinical Professional's Name or Supervisor's Phone Number (format: 555-555-5555)

Please explain your medical background to include any mental illness and what benefits would a service dog provide.

Living Situation & Animal Care

Your household? Please list names / ages / relationship to applicant.

Have you ever re-homed an animal?

Please explain your re-homing experience.

Do you have any current animals?

Please provide a list of the type and age of current animals in your household.

Are you applying for a dog you currently own to be trained?

Please briefly explain dog’s age, height, weight and history.

Has the animal ever shown aggression?

Please briefly explain this history of aggression.

Rent or Own?

Do you have a fenced in yard? If not, can you provide consistent exercise?

Are you presently employed? Please include employer and work hours.

How long will animal be alone?

Supporting Documents

Please upload a copy of a government issued ID OR VA Identification Card Please upload a valid file (JPG,PNG,PDF). Size of image should not be more than 2MB.

Please upload your DD214 (Member 4 copy) OR current LES Please upload a valid file (JPG,PNG,PDF). Size of image should not be more than 5MB.

If you are active duty or a VA employee, please upload authorization from your employer / commander for Service Dog. Please upload a valid file (JPG,PNG,PDF). Size of image should not be more than 5MB.

Please upload a current doctor’s letter stating that you would benefit from a service dog. Please upload a valid file (JPG,PNG,PDF). Size of image should not be more than 2MB.

Please upload place of Rental agreement OR proof of home ownership.
Rental agreement must contain applicants name and pet addendum.
Home ownership documentation must contain applicant’s name. Please upload a valid file (JPG,PNG,PDF). Size of image should not be more than 2MB.

Applicant Survey

Please briefly describe why you chose to apply with Companions for Heroes and anything else you would like to share to help us better understand your application.

Would you be willing to speak with media/press, share video/photos, and speak with our partners to help us continue our work?*

How did you learn about Companions for Heroes (C4H)?*

Other (Explain Below)

T-Shirt size

Shared Information Consent

Please read the Shared Information Consent Agreement in full and agree below:

By submitting this application I hereby give the Companions for Heroes (C4H) Staff, authority to use the information (including my participation in the C4H program, verbal testimonies, quotations, photos, emails, text messages or any communication of any kind) shared by me on this day (the application date) or any day thereafter in any corporation-related promotional material including the C4H websites, brochure, media, press releases, and merchandise.

I acknowledge and agree that C4H, or others operating on behalf of C4H may disclose to the public information that I provide to C4H or its agents, including my Protected Health Information ("PHI"). This PHI may include my name, birth date, address, telephone number, diseases and ailments, medical records and treatment information. This agreement to disclose applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, as amended, and under the rules and regulations thereunder, as well as applicable state law.

C4H may use and disclose the information provided, including PHI, for the business purposes of C4H, including but not limited to education, fund raising, advertisement of C4H, and support of other veterans and individuals who C4H assists.

With respect to (1) all video footage, photographs recordings, and written materials provided by me to C4H in connection with the Companions for Heroes program; and (2) all print, video, film, recordings and written materials prepared by C4H or its representatives in connection with the Companions for Heroes program in which I appear or am referenced, including, but not limited to, photographs, print materials, commercials, film or video, social media posts, posting on websites or webcasts ((1) and (2) of this paragraph shall collectively be referred to as "Works"), I hereby grant to C4H and its designees, including assignees and others that C4H collaborates with, the unrestricted, perpetual, worldwide right to reproduce, copy, modify, create derivative works and otherwise use, display, distribute, exhibit, transmit and broadcast the Works or any part thereof in any media, means or embodiment, now known or hereafter to become known, including my voice, image and identity without further approval or payment to me of any kind. I also hereby waives any right of inspection or approval of my appearance in the Works.

Full Name

Today's Date