Veterans Moving Forward, Inc.
909 N. Washington St. Suite 410, Alexandria, VA 22314
1-866-375-1209  www.vetsfwd.org
Comfort/Therapy Dog Team Application
Application
Name of Primary Handler: _______________________________________________________
Name of Secondary Handler: _____________________________________________________
Address: ____________________________________________________________________
City: ____________________ County:
_________________________ State: _______________ Zip: _____________ ____________
Preferred means of communication:  Phone
 E-mail
Best time to call?
_____________
Daytime phone number:
_____________
 work  home  cell
Evening phone number:
_____________
 work  home  cell
Other (Please specify):
_____________
 work  home  cell
E-mail address: ______________________________________________________________
Are you a Veteran?  Yes  No Active Duty Military  Yes  No
What are your reasons for wanting to support VMF? __________________________________
____________________________________________________________________________
Name of Dog: ________________________________________________________________
Dog’s Date of Birth: ______________________ Age (minimum 18 months):
______________________________________
Breed/Color: __________________________________________________________________
____________________________________________________________________________
Sex:  Male – Neutered  Yes  No
 Female – Spayed  Yes  No
Copy of vaccinations and pertinent medical information provided:  Yes  No
Has the dog passed the AKC® Canine Good Citizen® test? If so, when? __________________
Is the dog/handler pair registered with Delta Society® Pet Partners®?  Yes  No If so,
when? ______________________________________________________________________
Has the dog or handler previously been exposed to disabled person/s?  Yes  No
If so, provide details ____________________________________________________________
____________________________________________________________________________
Has the dog or handler previously been participating in animal-assisted activities/therapy in
hospitals or other health care facilities?  Yes  No
If so, provide details ____________________________________________________________
Is the comfort dog handler emotionally prepared for visiting with potentially extensively disabled
veterans?  Yes  No
Release of Claims for Accidental Injury
Page 1
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Comfort/Therapy Dog Team Application
I, __________________, of City of ____________________, State of ______________, hereby
certify I am aware of all the inherent dangers of handling dogs (mine and others) and of the
basic safety rules for activities connected therewith. I understand that canines require constant
training and evaluation and I understand my obligation and responsibility to do so and to seek
out recertification or evaluation at least once a year. Should the training, skills or temperament
of the canine regress for any reason or any behavioral concerns or illness present in my canine,
I understand I am to withdraw my dog immediately from active work until the canine is cleared
by a Doctor of Veterinary Medicine (DMV) and Veterans Moving Forward’s (VMF). I understand
that while I am participating in this program, I am responsible for any incident that might occur,
and absolve and agree to hold harmless VMF from any liability.
I also understand and agree that neither VMF or its officers, directors, members, trainers or
agents may be held liable in any way for occurrence in connection with said activities which may
result in injury, death or damages to myself, family or my dogs. In consideration of being
evaluated by this organization, I hereby personally assume all risks which may befall me while I
am engaged in this activity whether foreseen or unforeseen and further hold harmless the above
mentioned entities and persons from any claim by me, or my family or any other party arising
out of my participation in this activity.
I further state that I am of lawful age and legally competent to sign this affirmation and release,
which I understand. I have fully informed myself of the contents of this affirmation and release
by reading it before I signed it. I assume my own responsibility of physical fitness and
capability to perform under the normal requirements of the activity.
I have provided VMF with all official documentation or certification of my canine’s AKC® Canine
Good Citizen® test and Delta Society® Pet Partners® Program evaluation and attest that my
canine will always be groomed and in good health when participating in a VMF event. I have
read and agree to abide by VMF’s Policies while participating with this organization. I
understand my dog is not a service dog with public access rights or privileges under Federal or
Virginia Law. In Witness whereof, I have executed this affirmation and release on:
Prospective VMF Volunteer (Print name): ___________________________________________
Date: _________________
Signature: ___________________________________________
Prospective VMF Volunteer (Print name): ___________________________________________
Date: _________________
Signature: ___________________________________________
VMF Representative/Witness: (Print name): _________________________________________
Date: _________________
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Signature: ___________________________________________
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Comfort/Therapy Dog Team Application
Please return the completed application to:
VETERANS MOVING FORWARD, INC., 909 N. Washington St. Suite 410, Alexandria, VA 22314
or scan and create a PDF document and send as an e-mail attachment to admin@vetsfwd.org.
Page 3
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.