Golden Hearts Application

THANK YOU FOR YOUR INTEREST IN THE GOLDEN HEARTS SENIORS’ PET SUPPORT PROGRAM

Please fill out the application below with as much detail as possible. Once you submit your completed form, you will receive an automated email to acknowledge we received your application successfully. Your application will be processed within one to two weeks and you will receive a Golden Hearts membership card in the mail. The information you are supplying AWLQ in this Golden Hearts application form will be kept confidential and not sold to any third parties.

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Name
Date of birth
Address
EMERGENCY CONTACT
Address of emergency contact
Note that your emergency contact number should be a different number to your own.
You agree that the person you have listed as your emergency contact person above has the authority to make decisions in relation to your pet on your behalf in the event that AWLQ is unable to contact you. You agree that you are financially responsible for any decision made by your emergency contact person, which incurs an expense to AWLQ which is not covered by your chosen Golden Hearts Program and you agree to reimburse AWLQ in the event of any such expense. You will not hold AWLQ responsible for any decision made by your emergency contact person which may be different to the decision you would have made.

PETS INFORMATION

Animal Details

Is your animal male or female?
Is your animal desexed?
Are you looking for a pet?
Under S.T.E.P.S. (p10) if something should happen to you while your pet is in AWLQ's care and you are no longer able to provide for your animal, please advise us who you would prefer your pet(s) went to preferences
*Short Term Emergency Pet Care Service
Golden Hearts Foster Carer
Looking after someone’s pet is a big responsibility and there are certain things to keep in mind when short-term fostering someone’s pet. This is a free service that we offer senior-aged people in the community. Dogs must always be walked on a leash, never taken to an off-leash park and must be kept inside unless you have a well fenced yard. Cats must always be kept inside and windows/security grills closed.
Is there anything else that you would like to add?
DECLARATION - Please read the important information below and if you agree to each paragraph, click the tickbox to the left before you submit:
DECLARATION
DECLARATION (copy)
Price: $25.00