Veteran Application for Canine Community Corps
Thank you for your interest in Canine Community Corps (CCC). CCC provides emotional support animals
(ESAs) for veterans who experience the symptoms of Post Traumatic Stress Disorder. CCC does NOT
provide service dogs—e.g., those that help people with physical disabilities by pulling wheelchairs,
picking up dropped objects, leading the visually impaired, etc.
If you are interested in participating in our program, please complete the following application and send
it to:
CCC
PO Box 245
Eliot, ME 03903
or email to: info@caninecommunitycorps.org
Applicant Background
Name ________________________________________________________________________________
(Last)
(First)
Address______________________________________________________________________________
Phone _______________________________________________________________________________
Email Address _________________________________________________________________________
Birth Date (Month/Day/Year) _____________________________________________________________
Gender _______________
Nearest Relative/Significant person, address, phone, email _____________________________________
_____________________________________________________________________________________
Branch of Service ______________________________________________________________________
Dates of Service _______________________________________________________________________
Were you deployed? _____ yes _____ no If yes, when? ________________ Where? ________________
Date of Discharge ______________________________________________________________________
Employment Information
Are you currently employed? _____ yes _____ no
If yes, please complete the following.
Employer ____________________________________________________________________________
Title/Position _________________________________________________________________________
Hours per week _______________________________________________________________________
Medical Information
Are you receiving benefits from the VA for a military-related disability? __________________________
If yes, what is the diagnosis? What is the percentage? _________________________________________
Did you receive your injury while you were serving in the military? ______________________________
To the best of your ability, please describe the cause of your disability. ___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How would you describe your relationship with substances, such as alcohol, cannabis, etc.? __________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are the effects of your disability? Please check all that apply.
_____ Repeated disturbing memories
_____ Repeated disturbing dreams
_____ Panic attacks
_____ Chronic anxiety
_____ Being super-alert
_____ Jumpy or easily startled
_____ Avoid specific situations because they remind you of the past
_____ Avoid specific situations because you fear you will feel uncomfortable (e.g., avoid crowds)
_____ Loss of interest in daily activities
_____ Isolating yourself from others
_____ Feeling emotionally numb
_____ Difficulty concentrating
_____ Other (please describe)
Primary Care Physician _________________________________________________________________
Mental Health Care Professional _________________________________________________________
Housing
Please list everyone who lives in your household. Include each person’s name, relationship, and age
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Are any of the people in your household allergic to dogs? ___________________________________
Does anyone in your household have concerns about having a dog in the home? If so, please describe.
__________________________________________________________________________________
__________________________________________________________________________________
Do you own your home? _____ yes _____ no
Do you rent a house? _____ yes _____ no
Do you rent an apartment? _____ yes _____ no
Other (please explain) ____________________________
Do you have access to a yard at your home? _____ yes _____ no
Do you have access to a fenced yard at your home? _____ yes _____ no
Do you have pets/animals living in your home? If yes, please list type, name, breed, age.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you have the ability to care for a dog, including regular walks and ongoing training? If no, please
explain. ___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Experience with Dogs
Have you ever had a dog? If yes, please describe your experience with the dog.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do other animals live in or frequently visit your household? If yes, please describe.
__________________________________________________________________________________
__________________________________________________________________________________
Will you commit to ongoing training of your dog so that it becomes a certified Emotional Support
Assistant? Training classes will take place once a week for up to 6 months after you adopt your dog.
(Each dog-vet team is different.) Each class will last 1 hour. You will be expected to work with your dog
in between classes so that the two of you master the skills being taught. _____ yes _____ no
CCC covers the initial costs associated with the dogs, including adoption fee, spay/neuter, vaccinations,
and basic training. You will need to be prepared to pay for the ongoing care of the dog. The ASPCA
estimates that it will cost at least $700 per year to care for a medium-sized dog.
Can you afford the cost of caring for a dog? _____ yes _____ no
How do you feel an emotional support assistant or therapy dog would affect your life?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Words to describe the dog you would want. Please check all that apply.
Calm
Energetic
Playful
Serious
Friendly
Protective
Confident
Submissive
Criminal History
Canine Community Corps will conduct a background check on all applicants.
Have you been charged with any criminal offenses? _____ yes _____ no
If yes please explain_______________________________________________________________
Have you ever been convicted of any crimes? _____ yes _____ no
If yes please explain_______________________________________________________________
Do you have a history of violence? _____ yes _____ no
If yes please explain_______________________________________________________________
Do you have a history of harming animals? _____ yes _____ no
If yes please explain_______________________________________________________________
Have you ever become so angry/frustrated that you have struck someone? _____ yes _____ no
If yes please explain_______________________________________________________________
Do you have a history of fighting? _____ yes _____ no
If yes please explain_______________________________________________________________
Have you ever harmed yourself, i.e. cutting, burning, and hitting self? _____ yes _____ no
If yes please explain_______________________________________________________________
Consent to Contact
I, _____________________________________________, give consent for the health care professionals
listed below to release to Canine Community Corps information relating to my current physical health,
mental health, and home/work/school environments. I understand that the information requested is
confidential, will not be released to any person or agency outside Canine Community Corps, and will be
used for the sole purpose of assessing my qualifications for an emotional support or therapy dog and my
ability to provide a suitable home for a dog.
Please list the names, addresses and phone numbers of those who are applicable:
Primary Care Doctor ____________________________________________________________________
Address/City/State/Zip__________________________________________________________________
Phone Number________________________________________________________________________
Psychologist/Psychiatrist/Other Mental Health Provider
Address/City/State/Zip__________________________________________________________________
Phone Number________________________________________________________________________
Personal Reference
Address/City/State/Zip__________________________________________________________________
Phone Number________________________________________________________________________
Canine Community Corps would like the opportunity to share your story with news media, social
networking, video, promotional material, etc. Would you agree to share your story to help others that
may need our service? _____ yes _____ no _____ yes, within specific parameters (please describe)
_____________________________________________________________________________________
_____________________________________________________________________________________
I certify that, to the best of my knowledge and belief, the information provided in this document truly
represents my needs and present situation. I understand that failure to give complete information,
falsification or misrepresentation of information may prevent me from receiving a dog. I authorize
investigation of all statements made in this document and further authorize educational institutions,
employers, medical professionals, criminal justice agencies, and others to furnish whatever detail is
available concerning my application for a dog.
My signature below further authorizes Canine Community Corps to obtain criminal background
information and financial credit verification for the purposes of determining my ability to maintain and
care for a dog if one is provided by Canine Community Corps. All information shall be used solely for the
purpose of this transaction. A photographic or facsimile copy of this authorization bearing a
photographic facsimile copy of the signature of the undersigned may be deemed to be equivalent of the
original hereof and may be used as a duplicate original. I understand that any information obtained by
Canine Community Corps is confidential, will not be released to any person or outside agency without
my written consent, and will be used for the sole purpose of assessing my qualifications for a dog.
I agree that I or any member of my family, legal authority, friend, acquaintance, etc. hold Canine
Community Corps harmless from any liability.
Signature _________________________________________
Date _____________________________________________
Hold Harmless Agreement
I, _____________________________________, my successors and assigns, hereby agree to save and
hold harmless Canine Community Corps, or any employees and associates of Canine Community Corps,
including any animals used in training from all cost, and damage incurred by any of the above, and from
any other injury or damage to any person or property whatsoever, any of which is caused by an activity,
condition or event arising out of performance, preparation for performance or non-performance of any
provision of this agreement by Canine Community Corps. The above cost, injury, damage or other injury
or damage incurred by or any of the above shall include, in the event of an action, court costs, expenses
of litigation. I agree that I or any member of my family, legal authority, friend, acquaintance, etc. hold
Canine Community Corps harmless from any liability.
Signature______________________________________Date__________________________________
No Questions Asked Policy
I,______________________________________, understand that at any time if I do not comply with
the procedures and guidelines of Canine Community Corps, I can be removed from the program. I will
also be removed immediately for abuse of any animal, lack of participation and disrespect. Canine
Community Corps will not reimburse me for any expenses I have incurred while the dog has been in my
care.
IN WITNESS WHEREOF, the parties hereto set their hands this ___________day of__________________
20_________
Applicant_________________________________________________________Date________________
Canine Community Corps Representative _______________________________Date________________
Dog Removal Policy
I,______________________________________, hereby give Canine Community Corps the right to
remove a dog from my care in the event of mistreatment, abuse, poor living conditions, or in the event
that I become unable to care for my companion animal.
I agree that if, for any reason, I am no longer able or no longer wish to care for the dog I receive from
Canine Community Corps, I will return it to Canine Community Corps.
Signature______________________________________Date__________________________________