Become A Pets On Wheels of Connecticut Recipient

Congratulations on taking the first step to becoming a Pets on Wheels of Connecticut recipient!
We hope the following gives you an overview of our service and answers many of your questions.

After receiving a referral from a professional in our network, we ask that you fill out our Recipient Application below.

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* Denotes Required Information

Name *
Address *
City *
State*
Zip Code *
Phone Number *
Referred By *

If you need assistance, will it be:
Temporary	Long-Term
If Temporary, for how long?
What type of assistance are you requesting:
Provide food for the animal
Payment of adoption or licensing fees
Medical care*(must be pre-authorized by Pets on Wheels)
Transportation to veterinary appointment
Other (Flea/Tic Protection, Heartworm)
GENERAL
Please describe the age and gender of members of your household.
Have you owned a pet before?
If yes, please describe type of pet and level of experience
Have you personally been responsible for the care of a pet?
Will the animal be left alone during the day?
Would you prefer a
Would you consider an older animal?
Would you consider an animal that requires daily medication (if provided)?
If yes, do you have experience administering oral medications?
Do you have experience administering injections?
Additional Info For Dog Ownership
Do you live in a:	House Condo Apartment
Would there be anything preventing you from walking a dog on a daily basis?
Do you have a backyard?
If no, do you have an area to install a dog run?
If yes, is it fenced?
Will the animal be left alone during the day?

*All volunteers and recipients will have to sign "Hold Harmless" agreements in addition.
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