Military/Veteran Pet Assistance Submission Form -

Confidentiality Policy: Any personal information provided to our organization is not shared outside of Guardian Angels for Soldier’s Pet© and only shared with those within the organization that has a need to know. We follow OPSEC (Operations Security) guidelines, any Military and/or VA confidentiality polices, and HIPPA regulations in regards to confidentiality and sharing of information.

SECTION 1: PRIMARY ASSIGNED CASE WORKER’S CONTACT DETAILS

Full Name

Title

Medical Center/Organization Name

City

State

Business Phone

Cell Phone

For after-hours emergency purposes only

SECTION 2: SITUATION

Check only one option

Wounded Warrior

Veteran Medical “Inpatient” Situation

Homeless Veteran

SECTION 3: PET FOSTER TERM

Check only one option

Pet foster related less than 30 days (MPA related expenses)

Foster Home care needed (anticipated between 2 - 12 months) - Submit Pet Submission form

Foster Home Needed by

SECTION 4: EXPLANATION

Please provide pertinent information pertaining to this particular situation, since the more and detailed information we have, the better we are able to determine how we may assist.

SECTION 5: MILITARY/VETERAN’S CONTACT DETAILS

Branch of Service (active duty or veteran)

Rank (active duty only)

First Name *

Last Name *

City *

State *

ZIP Code *

Primary Phone Number *

Email Address *

Pet's Current Location

Enter the city and state that the pet is located in.

SECTION 6: PET(s) INFORMATION

Reminder: 1 submission per pet if you have more than 1 pet required to be fostered.

Number of Pet(s) Involved with Request

Type of Pet(s)

Canine

Feline

Name(s) *

Breed

Gender

Male

Female

Pet(s) is Spayed (female) or Neutered (male)? *

Yes

Pet(s) is Micro Chipped? *

Yes

Pet(s) is current on Shots (including but not limited to rabies, Distemper, Bordetello) based on individual state laws? *

Yes

Pet(s) Photo

Please upload a current photo of the pet.

SECTION 7: SUBMT

My full name entered below indicates that as the assigned case worker, I am authorized by the active duty military or veteran legal pet owner to submit this request and declare the information provided for this submission is accurate, complete, and true.

In addition, I confirm and understand by providing my name below that entering incomplete or false information can result in Guardian Angels for Soldier’s Pet© rejecting this request or can delay our ability to assist you in a timely manner.

Case Worker's Signature

Use cursor to sign below.

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Date Prepared

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