Skilled Home Companion Application

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Application to Adopt a Skilled Home Companion

Please review the general information and requirements for adoption of a released dog on our website. In particular, if you are interested in adopting a dog as a Skilled Home Companion, please be sure you have read the information on this page. If you have remaining questions, please send an email to hero@hero-dogs.org.

Please plan to complete this entire application in one sitting; otherwise it may time out and you will lose your information. Once complete, you will automatically receive an emailed copy of your application. If we feel that you may be a good fit for a currently available dog, we will contact you to schedule an interview.

First Name *

Last Name *

Street *

Street2

City *

State *

Zip *

Phone *

Alt Phone

Email *

Are you a: *

Veteran of U.S. Uniformed Services

Guard or reserve

First responder

None of the above

Active duty military or PHS

Family member of one of the above

If applicable, please give affiliation(s) and dates of service (NOTE: copy of DD-214 or employment record will be required to waive adoption fee).

Are you seeking a: *

Skilled Home Companion dog for yourself

Skilled Home Companion dog for a family member

Please tell us why you are interested in adopting a Skilled Home Companion from Hero Dogs: *

Most of our dogs will be Labrador or golden retrievers, but there may be other breeds from time to time. Is there any breed of dog you would NOT want to adopt?

Do you feel you need a dog of a particular gender? *

If there is a restriction, please explain:

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Are you seeking a SHC dog for:

Yourself

An immediate family member residing at your address

If for a family member, please give that person's:

Name:

Relationship to you:

Please answer the remaining questions for the person for whom the dog is requested.

Height:

Weight:

Age:

Please describe your relevant medical condition(s) or disability.

What do you consider the biggest challenges you face in your daily life as a result?

Please describe any other limitations on your activities of daily living.

Is your current medical condition stable?

If you selected "NO" or "UNSURE," please elaborate.

Please describe your current or ongoing treatment plans (e.g. counseling, medication management, physical or occupational therapy, etc.).

Please list any assistive equipment you use (e.g., wheelchair, cane, hearing aids, etc.) and the approximate percentage of time that you use it.

Are you able to walk, either unaided or with use of crutches/braces/cane?

What are your current hobbies, interests, and activities?

Please describe your goals and expectations for your / your family's relationship with a Skilled Home Companion dog. What are you hoping to achieve?

Specifically how do you think a dog might help you with your medical condition or disability? What skills or tasks would you like the dog to have or be able to do?

Do you plan to move within the next 6-12 months? *

If YES, please give the city and state to which you plan to move.

I understand that a Skilled Home Companion dog is NOT a service dog, and that I will not have public access rights. *

I understand that there is a training requirement for the placement of a Skilled Home Companion dog. *

I understand that additional medical information and/or a background check may be required as part of this application process. *

If I am accepted and matched with a Skilled Home Companion Dog, I agree to follow all of Hero Dogs' rules and recommendations regarding the care, safety, feeding, supervision, and training of the dog. *

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Household Information

List all of the members of your household, their relationship to you (spouse, child, roommate, etc.), occupation, and the hours that person is away from home on a typical workday (e.g. 8 a.m. - 4:30 p.m.). Please give ages of children.

EXAMPLES:
John Smith (self), restaurant manager, away from 7:00 a.m. - 6:00 p.m., M-F
Mary Smith (spouse), accountant, works from home
Peter Smith (son), age 9, away from 8:30 a.m. - 3:30 p.m., M-F
Judy Smith (daughter), age 3, away from 8:30 a.m. - 11:30 a.m., M-F

Yourself

Person #2

Person #3

Person #4

Person #5

Person #6

Is everyone in the household in agreement about receiving a dog? *

If NO, please explain:

Is anyone in the household allergic to dogs? *

Is anyone in the household afraid of dogs? *

If YES, please explain:

Do you expect children in the household to take on responsibilities for this new dog? *

If YES, please describe the responsibilities you envision for the children.

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Other Pets

Have you previously owned other dogs as an adult? *

If YES, what breeds or mixes?

What became of them?

Have you ever personally obedience trained a dog? *

Yes, in group classes

Yes, with a private trainer

Yes, on my own

Please list all pets currently in the household.

Pet #1 Name

Species

Breed

Gender

Age

Pet #2 Name

Species

Breed

Gender

Age

Pet #3 Name

Species

Breed

Gender

Age

Pet #4 Name

Species

Breed

Gender

Age

If you currently have dogs, are they:

House dogs

Outdoor dogs

Please describe how your dogs react when people approach your yard/house or visit your home.

Please describe how your dogs react when they see or meet people out on a walk or away from your home.

Please describe how your dogs react when they see other dogs at a distance (e.g. on walks, at the vet, out the window).

Please describe how your dogs react when they meet/greet other dogs up close.

Do you currently have a veterinarian? *

If YES, please provide contact information:

Doctor's name:

Clinic name:

Street address:

City, State, Zip

Phone:

How long have you been taking your pets to this veterinarian?

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Home Environment

Does anyone in your household smoke inside the house? *

Which best describes the area in which you live? *

What type of home do you live in? *

Do you own or rent your home? *

NOTE: if rented, a copy of lease or written permission from landlord will be required.

If OTHER, please explain:

Do you have a fenced yard? *

Yes, physical fence

Yes, electric fence

If fenced, please describe the type of fencing and give the height of the fence and the approximate size of the enclosed area (e.g., 6 ft. stockade fence, 0.25 acre).

How many hours will the dog be left at home alone on a typical workday? *

Please describe where the dog will be kept when at home alone. *

Please describe where the dog will sleep at night. *

Can you arrange reliable transportation to attend our training? We are not accessible via public transportation or Uber/Lyft/etc. *

What do you estimate the average yearly cost of owning a dog (65 lbs., average health) to be over the life of the dog? *

What do you estimate to be the average cost of an emergency veterinary visit, involving surgery and an overnight stay? *

How much time can you commit, on a daily basis, to providing physical and mental exercise to a dog? *

Please describe how you will provide physical and mental exercise to a dog on a daily basis. *

If you are temporarily unable to care for the dog (exercise, feed, toilet) due to illness or injury, who will commit to caring for the dog for you? *

Please describe your plans for care for the dog when you travel. *

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References

Please give contact information for two personal references:

References should NOT be family members
References should NOT be household members
References should NOT be Hero Dogs staff members
At least one of your references should be someone you have known for longer than one year.

We will NOT share any personal information you have provided on this application with your references. However, please contact your references to tell them that you have applied to adopt a dog and to expect a call from a Hero Dogs representative. Please make sure you provide a current phone number and email address - we will not consider your application until we have successfully contacted your references.

Reference #1

Name: *

Phone: *

Email: *

Address: *

City: *

State: *

Zip: *

How do you know this person? *

How long have you known this person? *

Reference #2

Name: *

Phone: *

Email: *

Address: *

City: *

State: *

Zip: *

How do you know this person? *

How long have you known this person? *

Other Information

How did you hear about Hero Dogs? *

Is there anything else about you or your family that you think we should know when considering you to adopt a released Hero Dog, or to help us to match you with the most suitable companion?

Waiver of Liability

I understand that applying for a Skilled Home Companion (SHC) dog from Hero Dogs, Inc. may bring me into contact with dogs and that there is an inherent danger in any activity involving animals. I assume the risks of being bitten, scratched, injured, and/or frightened by dogs in connection with applying for a SHC dog from Hero Dogs. I also assume the risk that my personal property may be damaged or destroyed by dogs in connection with my activities with Hero Dogs. I understand that persons other than myself may be contacted by Hero Dogs personnel in connection with my application and that, while every attempt will be made to ensure confidentiality, such contact may result in disclosure of my private health care information and I assume this risk. I agree to indemnify and hold harmless the Hero Dogs organization, officers, directors, volunteers, their family members, heirs, personal representatives, and agents for any injuries, damages, liabilities, losses, judgments, costs, and/or expenses which I or my family might suffer in connection with my activities with Hero Dogs.

Signature *

Date *

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