RELEASED DOG APPLICATION
SECTION 1
Applicant’s Name: ______Date: ______
Thank you for your interest in a released dogfrom Canine Partners for Life. A dog may be released for a variety of reasons – the most prevalent being that some are adopted from area shelters and during the course of training, it may be discovered that the dog is simply not appropriate to be trained with the skills necessary for service work but will make a wonderful pet. Unfortunately for those wanting to adopt our released dogs, only a few are released each year.
Once your application is received, your name will be placed on our waiting list for released dogs. When these dogs do become available, we notify the next applicant on the waiting list that we feel matches best with the dog. (For example, a cat-focused dog will not be placed in a home with cats.) The applicant, along with their family members, is then invited to come to the CPL facility to meet and interact with the dog. If the applicant is interested in adopting the dog, references are checked and the applicant is notified if they are chosen for the placement.
We do ask for a $300 donation to adopt a dog released from our program. All dogs are micro chipped, up to date on their shots and have received training in basic obedience. The extent of training will be reviewed with the applicant at the time of placement.
Canine Partners for Life is an accredited member of Assistance Dogs International. CPL respects the privacy of its applicants and recipients and all information is kept confidential although files may be periodically reviewed by accreditation agencies to ensure CPL’s commitment to the highest standards of excellence in the assistance dog industry.
Canine Partners for Life conducts its business and acceptance process in a manner that will not discriminate against anyone on the basis of race, color, religion, gender, national origin, age, the presence of mental or physical disability, sexual preference, life expectancy, or whether the individual is a disabled veteran or veteran of any era. It is Canine Partners for Life’s policy to treat everyone who comes in contact with the organization with respect and dignity at all times.
At no time will Canine Partners for Life require applicants, students, or graduates to participate in fundraising or marketing activities.
I have read, understand, and agree to SECTION 1 of this application (please initial): ______
SECTION 2
Applicant’s Name: ______Date: ______
Applicant’s Home Address:______
______
County: ______
Phone: (Home) ______(Work)______(Cell)______
E-Mail Address: ______
Birth Date: ______
Social Security Number: ______
Presently: ______Student ______Employed ______Unemployed ______Retired ______Other
Emergency Contact Person/Telephone:______
If a student, please list current grade, name and address of school:
______
______
If employed, please list employer’s name and address:
______
______
Family members residing in home and their schedules (please include ages):
______
______
Do you own or rent your home?______
If you rent, do you have a pet policy? _____ Yes _____ No
If so, please include a copy of the policy or a letter from your landlord permitting the dog to be present.
SECTION 2 CONTINUED
Applicant’s Name: ______Date: ______
Approximately what percentage of the day are you away from home? ______
Do you travel? ______Yes ______No
If so, where and how often? ______
______
______
Do you currently have any pets? ______Yes ______No
If so, what types of pets do you have and what are their ages:
______
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Do you have a fenced yard? ______Yes ______No
If no, are you ALWAYS willing to walk dog on leash?______
______
Do you have any experience working with dogs? ______Yes ______No
If yes, please explain: ______
______
Reason for interest in dog: ______
______
Are you willing to adopt a dog with special medical needs? ______Yes______No
Are you willing to adopt a dog with behavioral challenges? ______Yes______No
SECTION 2 CONTINUED
Applicant’s Name: ______Date: ______
Are you a member of, or do you support financially, any animal rights organizations (example PETA)?
______Yes ______No
If yes, please explain in detail the level of your involvement: ______
______
______
______
Have you ever been convicted of a misdemeanor, summary offense, or felony related to the abuse, mistreatment, neglect or harm to animals? ______Yes ______No
If yes, describe in detail including the state and date in which the conviction was made: ______
______
______
Who referred you to CPL? ______
I have completed SECTION 2 of this application to the best of my knowledge and with information that is true and correct.
Applicant’s Signature: ______
SECTION 3
Applicant’s Name: ______Date: ______
Canine Partners for Life
Complaint Policy for Non-employees
Any non-employee (volunteer/applicant/student/recipient/donor) who has a grievance concerning CPL practices has the right to file a complaint according to procedures outlined in this policy. Grievances may include, but are not limited to, a perception of violation of rights; quality of service; discrimination based on category of race, age, disability, etc.; or other matter.
Complainants are treated with dignity and respect at all times, regardless of the nature of their complaint. They will not be discriminated against, harassed, intimidated, or suffer any reprisal as a result of filing a complaint or participating in an investigation of a complaint. If an individual feels that he or she is being subjected to any of the above, that person has the right to appeal directly to the Executive Director.
Affected parties should attempt to resolve the problem informally as soon as possible. Volunteers should discuss issues with the Volunteer Coordinator, donors with the Director of Development, and applicants/students/recipients with their trainer. If a solution cannot be reached, the person may present a formal complaint, in writing, to the Executive Director. Formal complaints and responses to them will be documented and kept on file.
All complaints are handled in a timely manner. As a goal, CPL attempts to resolve a complaint within 20 working days from the time of its initiation. If an extension of the time limit becomes necessary, all involved parties will be notified.
I have read, understand, and agree to SECTION 3 of this application.
Applicant’s Signature: ______
Parent/Guardian’s Signature if Applicant is under the age of 18 years:______
Please include with your application the following:
1. A LETTER OF REFERENCE
This letter must be written by someone outside of your immediate family.
2.CONTACT INFORMATION FROM A LOCAL VETERINARIAN OF YOUR CHOICE
Return this complete application along with the letter of reference and contact information from a veterinarian to Canine Partners for Life, P. O. Box 170, Cochranville, PA19330. Please allow 2-3 weeks for processing. If you have further questions regarding the Canine Partners for Life application or released dog program, please call (610) 869-4902 x 212.
Fax (610) 869-9785
Canine Partners for Life Released Dog ApplicationPage 1 of 5
Revised 1/25/2013