PAWS FOR PURPLE HEARTS RUTHER GLEN, VAPUPPY PARENT APPLICATIONThis application should be completed by the primary person or people who will be working with the puppy.Unable to utilize this form or prefer to fill it out by hand?Download our PDF Application, and mail or email it directly to us. I have read and understand the Overview, Responsibilities, and Qualifications as detailed on the previous page. * YES NO Name * First Name Last Name Email * Are you a veteran or service member? * YES NO Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Daytime Phone * (###) ### #### Evening Phone (###) ### #### Cell Phone (###) ### #### How did you learn about Paws for Purple Hearts and our Puppy Parent Program? * Why do you want to be a Puppy Parent for a service dog in training? * Primary Handler Name * First Name Last Name Age * Occupation * Do you, or does anyone in your household, smoke (cigarettes or marijuana)? * YES NO Can you commit to refraining from smoking near the dog, including in your home? * YES NO Secondary Handler Name * First Name Last Name Age * Occupation * Other Household Members Name First Name Last Name Age Occupation Name First Name Last Name Age Occupation Name First Name Last Name Age Occupation Lifestyle and Routines Please describe how you spend a typical day. Weekdays * Weekends * Please tell us about your schedule. When are you able to care for the dog in your home? (check all that apply) * On weekends only On weekends and weekday evenings On weekday evenings only Other extended periods of time as needed Over the holidays, such as Thanksgiving and Christmas Please specify other times you are able to care for dogs in your home * Please tell us about your household. In what type of residence do you live? * House Townhouse Apartment/Condo Dorm Do you own or rent your residence? * OWN RENT Can you provide written verification that dogs are permitted in your residence? * YES NO If you are renting please provide your landlord's name First Name Last Name Landlord's Phone (###) ### #### Do you have access to a yard at your residence? * YES NO Is the yard fully fenced in? * If you do not have a yard, choose NO. YES NO Please describe the type of fence you have including the height. * If you do not have a fenced yard, type NA. Do you have a pool at your residence? * YES NO Is the pool fenced? * If you do not have a pool, choose NO. YES NO How much interaction do you anticipate the puppy will have with other dogs in your neighborhood? * Dog Care Experience Have you ever owned a dog(s)? * YES NO Dates of ownership and what breed(s)? Puppies Have you ever raised a puppy? * YES NO Have you potty trained a puppy? * YES NO Have you crate trained a puppy? * YES NO Current Pets Do you currently own any pets? * YES NO What type(s), breed(s) and age(s)? Are your pets neutered or spayed? YES NO Can you provide proof of vaccinations for your pets? YES NO Please provide the name and phone number of your veterinarian. Does your dog(s) have any behavior that could be problematic with a new puppy in the house? YES NO Please describe potential problematic behavior : Dog Training Experience Have you ever attended dog training classes? * YES NO Dog training classes experience Obedience Agility Show Tracking/Search and Rescue Assistance Dog puppy raising with the following organization If you have attended Assistance Dog Training please list the organization. Other type of training experience Please tell us what life will be like with a service dog puppy. Do you accept that Paws for Purple Hearts will not be responsible for any destruction by the dog to your house, household items, yard, car, school, or workplace? * YES NO Do you acknowledge that the puppy may have toileting accidents in your home? * YES NO Do you plan to take the dog to * School Work Neither Do you have permission to take the dog to work or school (if necessary) * YES NO If you will be taking the puppy to work or school with you, how many days a week? * Type NA if not applicable. If you will be taking the puppy to work or school with you, how many hours a day? * Type NA if not applicable Where do you work or attend school? * Type NA if not applicable. What kind of environment would the dog be exposed to at work or school? * Type NA if not applicable. If you can’t take the dog to work or school, where will the dog stay? How many hours will it be alone? * Type NA if not applicable. In what situation(s) would you not take the dog with you? * If you must leave the dog alone at home, where will the dog stay? * Sleep, Exercise, and Socialization Where in the house will the dog sleep during the night? * How will you exercise the dog and how often? * Are you committed and willing to take the dog with you on public outings, such as the grocery store, zoo, movie theatre, mall, etc.? * Please note that you are responsible for the safety and positive exposure of the dog to public places and experiences, such as crowds, traffic, construction, children, music and unusual environments. YES NO Commitment to Paws for Purple Hearts Can you commit to attending PPH training sessions? * (Session frequency and length may vary based on situation) YES NO Can you commit to filling out reports on the dog’s behavior and experience? * (Report submission timeline may vary based on situation) YES NO Do you consent to pre-announced visits to your home by a PPH representative before and during the time the dog is in your care? * YES NO Paws for Purple Hearts service dogs-in-training are male and female Golden Retrievers, Labrador Retrievers, and Golden/Labrador Retriever crosses, and may not be altered while in your care. Are you willing to parent a dog of any gender or breed? * YES NO References Reference Name * First Name Last Name Reference Phone * (###) ### #### Reference Email * Reference Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Volunteer Applicant Agreement and Liability Waiver In anticipation that you will be accepted into Paws for Purple Hearts’ Puppy Parent program, please read and sign the agreement below. I authorize Paws for Purple Hearts to seek emergency medical treatment in case of an accident, injury, or illness. I understand that if I am injured while acting as an unpaid member of the volunteer staff that I am not covered by applicable state Worker’s Compensation Law. I understand that working with dogs involves risks, including possible injury, illness, death, damage to or destruction of property, and I choose to volunteer with Paws for Purple Hearts of my own free will with full knowledge and acceptance of those risks. I indemnify and hold harmless Paws For Purple Hearts from and against any and all claims, losses, liabilities and damage to persons or property, expenses, costs and/or attorneys’ fees arising out of the acts or omissions of Paws For Purple Hearts, its directors, officers, agents or employees, and I agree that anything whatsoever that happens relating to the dogs, their training, or my volunteer work with dogs will not result in any claims against Paws For Purple Hearts, its directors, officers, agents or employees by me or anyone acting on my behalf for personal injuries or property damages. If I volunteer through the Department of Veterans Affairs (“VA”), Department of Defense (“DOD”), a state Veterans services department, or similar host organization, I understand and agree that any claims I may have that are related to the program will be referred to the host organization and that the host organization may, at its own discretion, pursue those claims further. Name * I acknowledge that the information contained on this form is true and correct. I understand that any misrepresentation of facts may result in the removal of the PPH dog from my home. First Name Last Name By checking YES I affirm that the information contained on this form is true and correct to the best of my knowledge. I understand that any misrepresentation of facts may result in the removal of the PPH dog from my home. I agree to abide by the requirements of the program to the best my ability and to enter into all agreements with PPH in good faith. * YES NO Your application is complete!Thank you for your interest in becoming a Paws for Purple Hearts Puppy Parent. We will review your application and will contact you after the review is complete. Please note the review will take approximately five business days. In the meantime, follow us on Facebook, Twitter, and Instagram for daily updates on our pups! Paws for Purple Hearts Successes 13,147Lives we’ve directly improved. 22,263Therapy session participation.**(session slots filled) Many Warriors attend multiple sessions. 159Dogs we’ve deployed.
