Pawsitive for Heroes New York Form

Name*

First Last

Signature*

Use your mouse or finger to draw your signature above

Date*

Address*

Street Address Address Line 2 City State ZIP Code

What County do you live in?*

Phone*

Email*

Date of Birth*

Marital Status

Branch of Service*

Military Status*

Combat Veteran?*

Yes
No

Were you in a Theater of Service?*

Yes
No

Please provide Theatre(s)

Are you a Purple Heart recipient?*

Yes
No

Please provide Purple Heart documentaion*

Drop files here or

Max. file size: 2 GB.

Wounded / Disabled?*

Yes
No

Please provide documentaion*

Drop files here or

Max. file size: 2 GB.

Please list any and all dependents of applicant (e.g., Spouse (age), Children (age/s) and if applicable, other - describe*

Do you currently have other animals residing with you?*

Yes
No

If yes, how many do you have and what type*

If you currently have a dog and interested in using him/her as your service animal, what breed is the animal/AGE/Male or Female

What type of dog would you be looking for?*

What sex would you be looking for

Male
Female
Doesn't matter

How many immediate familiy members? (including veteran)*

Are you able to support and provide proper care for a dog*

Yes
No

If no, who will be able to assist you with this care

Please explain how you would ensure the safety and well-being of your service dog*

Please provide any and all medical/psychological issues that you may be dealing with at this time*

I understand that I must get a letter from my Mental Health Provider attesting to the fact that a service dog would be helpful to me*

Yes
No

If you were to end up in hospital, who would take care of your dog*

Please list all who referred you to WNYHeroes, Inc. for help. We need the contact name/number (i.e. caseworker), the organization name (i.e. VA Hospital, American Legion, AMVETS, VVA, VOC, VOS)*

The following information is requested to verify you are able to afford and support a service dog prior to being accepting into the program. INCOME: Please list ALL sources of FAMILY income, including, but not limited to: any salary, social security, VA benefits, support from other organizations, investment income etc. for ALL household members residing at the same address.

List all income PER MONTH*

Total Income*

Please include ALL Family living expenses (i.e. rent/mortgage, utilities, insurance, food, transportation, medical, credit cards and other living expenses whether or not you are requesting assistance for that specific expense). For each expense, please indicate if the expense is a recurring expense or a one-time expense. Please explain any unusual or exceptionally large expenses.

Please list ALL EXPENSES per Month (Rent/Mortgage, Gas, Electric, Water, Cable, Cell Phone, Credit Cards, Car Loan, Car Insurance, LIST OTHERS)*

Total monthly expenses*

Please describe below the reason for the request*

I hereby authorize WNYHeroes to look into any and all information as needed. I also understand that if anything is said to be false, it can result in termination of the program and removal of such, to include but not limited to the service animal I will cooperate in any manner needed to speed up my request as WNYHeroes sees fit. I understand by not filling out the entire application or leaving blanks, that this can and will delay the process to the grant. I understand by taking part in this program, I will attend EVERY class as such scheduled and continue what is taught outside the classroom. I understand that at any point if the instructor(s) feel that I am NOT making progress, I can be removed from the list of participants and failure to make progress may result in the removal of the program provided by WNYHeroes, Inc. I understand that at any point if the instructor(s) feel my current service dog is not progressing, the instructor may change out the dog for a better fit. (i.e. lizard, worm, gerbil, turtle) I understand that upon completion of the program, any further training needed to keep my service/therapy dog certified and functional in their chief capacity remains my responsibility. If at any point I feel the dog needs further training, I will contact WNYHeroes or my instructors to discuss such. I understand by coming into this program, my service dog reverts to WNYHeroes, Inc. (Pawsitive for Heroes). Should I decide to leave the program at any time or leave the WNY area prior to my completion of program, I will be held liable to repay ALL COSTS to the organization. I understand that I MUST render the animal back to WNYHeroes, Inc. prior to exiting the program. Should I already have a dog prior to program and looking to take part in the program, I will only be held responsible for costs that WNYHeroes, Inc. has paid out. Meaning, my dog solely belongs to me. I understand that I am subject to one or more face to face interviews with the committee and that by refusing to do such is an automatic denial. Pawsitive for Heroes will cover cost for registry upon completion. I understand that I must take steps to educate myself on the difference between a therapy dog, emotional needs and service dog. With that, it is with the assistance of WNYHeroes, Inc. to educate me on the laws of such and any changes made to the law. Service dog: Assistants to individuals with disabilities (mobility, sight, hearing, and other physical and/or psychiatric issues). A service animal is to be touched ONLY by its handler. The exact number of service dogs around the world is not known; it is estimated in the tens of thousands Therapy dogs: Provide visitation to hospitals, nursing homes, rehabilitation facilities. A therapy animal is meant to be touched by everyone/anyone out in the community. Therapy dogs are not service dogs — and are not protected by the ADA regulations. Public institutions may limit or prohibit access to a therapy dog. Training required for a therapy dog designation varies, but it is much less rigorous than that of service dogs. By signing this sheet, I am agreeing that I have fully read and understood ALL differences between both service and therapy animals. I may go to the website given to me for further information. I understand that the training my dog and I will be given is for completion of CGC and Therapy Dog International. I understand that by NOT keeping my appointments as scheduled, still comes to a cost of WNYHeroes, Inc. If I am not keeping my scheduled appointments, I will be responsible for the cost of that particular day. I fully understand that at ANY time the organization feels the need to make a house visit; they may do so without notice. I fully understand and made aware that upon completion of course it is of my own liability to register and license my dog with my town, village or city in which I currently reside in. I release WNYHeroes, Inc. and its committee members of any and all liability if I should lose control of my dog and he/she attacks another dog or human being. I fully understand that upon completion, I am bound by both CGC, CGCU, CGCA and TDI to turn in ANY and ALL paperwork in order to register my dog and failure to do so would mean forfeiture of certification, causing me and my dog to possibly retake the entire course. Should you have to retake a section due to failure of upholding your end of the agreement. I am aware, should I decide NOT to complete the program or fail to continue due to my own faults, I am held liable to refund WNYHeroes, Inc. all expenses that were currently given to me. I understand, should I relocate from the WNY area during the program OR within one year of completion of training, I am bound to repay all costs back to WNYHeroes, Inc. determined at the time of failure. My service dog, equipment and thereof would also would have to be returned that was given to me. I am fully aware and give full consent to run a state wide criminal background check in order to be accepted into the “Pawsitives for Heroes” program. If for some reason I am not, someone from the program will contact me. I am aware that this program is STRICTLY for veterans of WNY and by submitting such request I am also confirming truth to my being eligible. By signing this document I am telling the truth and forthcoming with all information according to guidelines of WNYHeroes, Inc. By signing below, I understand and agree to all the above.

Veteran's Name*

First Last

Signature*

Date*

I hereby grant full permission to speak with my current or past caregivers. By allowing access to my medical or mental health status, this allows a decision to be made on being accepted or denied access to the WNYHeroes service dog program. I fully understand that by refusing to sign this wavier I am automatically denied. I understand that at no point will any information be shared transferred or divulged to hands of others outside of WNYHeroes without prior written consent to do such. I understand that at any point in time WNYHeroes or its committee members may call caregivers for status update on my health and well-being. I understand that by signing this wavier, I am allowing discussion between the VA hospital, Vets Center or other outside care providers and will fully cooperate as needed. I understand that any discussion of my records or hx may also be discussed with all parties involved with program, to include our professional trainers for the sole purpose of our animals. By having my caregivers sign and date, I am also making them aware of my intent and giving my permission to them as well to discuss my care with WNYHeroes, Inc. and it’s participation in the program. I am aware that I would need supporting documents, records or prescription type from such caregivers supporting my need of the program that a service dog would benefit my military issues at hand and by not doing such, I am not eligible.

Veteran's Name*

First Last

Signature*

Date*

Are you able and willing to volunteer at any of our events or in another way*

Yes
No

Please note: we are only able to provide notification for Special Event volunteering (i.e. Fairs, Festivals, Golf Tournament fundraisers, Motorcycle Runs, etc.) by email and on WNYHeroes.org and on our face book page.

Please specify if you have any special needs (sitting at Events due to trouble standing over long periods of time) (wheelchair access)

WNY Heroes, Inc. is an alcohol-free and drug-free organization. The purpose of this policy is to ensure the safety of all volunteers and to promote awareness. This policy applies to all volunteers of WNY Heroes, Inc. Substances covered under this policy include alcohol, illegal drugs, inhalants, and prescription and over-the-counter drugs. We reserve the right to inspect our premises for these substances. We will remove you permanently from our volunteer database if you violate this policy, or provide false information. Definitions under this policy: A “substance” includes alcohol, illegal drugs, inhalants, and prescription and over-the-counter drugs. An “illegal drug” is any substance that is illegal to use, possess sell or transfer. “Drug paraphernalia” are any items used or intended for use in making, packaging, concealing, injecting, inhaling, or consuming illegal drugs or inhalants. A “prescription drug” is any substance prescribed for an individual by a licensed health care provider. An “inhalant” is any substance that produces mind-altering effects when inhaled. You are “under the influence” if any substance: Impairs your behavior or your ability to work safely and productively Results in a physical or mental condition that creates a risk to your own safety, the safety of others, or property; including WNY Heroes, Inc. “Company Premises” – buildings, grounds, parking lots; and all inside and outside event locations and vehicles. You must adhere to these rules while you are a WNY Heroes, Inc. volunteer. The rules apply at/during any time you are volunteering, including but not limited to volunteer events, 3rd party events and within the organization’s offices, including your own vehicle. 1. Volunteers are not permitted to drink, possess, or be under the influence of alcohol while volunteering at any WNY Heroes, Inc. events, 3rd party events, on WNY Heroes, Inc. premises, at meetings, etc. 2. Volunteers are not permitted to use, possess, or be under the influence of illegal drugs. 3. Volunteers are not permitted to sell, buy, transfer or distribute and drugs or alcohol. It is against the law to do so, and we will report such actions to the authorities.

Agreement to follow WNY Heroes, Inc. Alcohol and Drug use policy: I have received and read a copy of the alcohol and drug use policy for WNY Heroes, Inc. I agree to follow the rules of this policy*

Yes
No

Name*

First Last

Signature*

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Checklist (check all that apply)*

Veteran's Name*

First Last

Signature*

Use your mouse or finger to draw your signature above

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Pawsitive for Heroes New York Form

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