Pets Healing Vets Program Application

Veteran Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alternate/Emergency Phone*

Email*

Date of Birth*

Branch of Service*

Military Status*

Active
Inactive

MOS

Duty Stations*

Conflicts Served*

Reason for Discharge*

PENDING AND/OR PRIOR CONVICTIONS*

Have you ever been charged with or convicted of a misdemeanor or felony? Do you have a pending charge against you?

Enlistment Date*

ETS Date*

How did you hear about the Pets Healing Vets program?*

Combat Related Diagnosis (list all):*

Have you, or are you currently, seeking treatment for the above referenced medical diagnoses? Please describe:*

Please help us understand what you feel a companion animal can bring to your life, and what you feel you can bring to their life:*

Do you feel able, ready and willing to open your home to a pet? Please elaborate:*

How many hours per day will your pet be left without human companionship?*

If accepted into the program, are you willing to allow PETS HEALING VETS to monitor you and your pet's progress, including but not limited to: scheduled home visits, phone call check-ins, vet checks?*

Yes
No

If accepted into the program, your pet will be given at no cost. However, pets require food, annual exams, occasional emergency care and other such expenses. Are you financially able to meet these requirements?*

Yes
No

Please list the names and ages of all people currently living in your home, as well as those who will frequently come in contact with your pet:*

Are all of the above aware of your desire to enter the program? Are they comfortable around animals, and are they in agreement with having a pet in your home for the life of the pet?*

Yes
No

Are you interested in a cat or dog?*

Cat
Dog
Either

Is there a specific breed, temperament, age or size you are most interested in?*

Are you willing to allow PETS HEALING VETS to make the final decision as to the pet that is best for you and your situation? We will take into serious consideration the animal in which you have an interest.*

Yes
No

Do you have any desire to adopt a special needs pet? This could be a pet with either a physical or mental/behavior issue. We will not adopt out any animal with human aggressive tendacies. If you would be interested, please explain why:*

Many of our animals need to learn basic obedience. Are you willing and able to continue your pet's training following the adoption of your companion? (Additional training is provided at no cost to the veteran.)*

Yes
No

Do you have any other pets currently living in your home, or pets that frequently visit? If yes, please provide us with the type of animal, age, breed and temperament.*

Please let us know anything else about yourself that you feel will help us determine your eligibility and to match you with the right pet.*

Help a vet. Help a pet.

Apply for a Dog or Cat