For Authorized Facility Use Only.
[Organization Name] CRiSP REQUEST FOR SERVICES – ELIGIBILITY FORM
This form is used by [Organization Name] to determine eligibility for participation in the
CRiSP Program. Completion of this form does not guarantee acceptance.
[Organization Name] reserves final discretion regarding eligibility and placement decisions.
SECTION 1: DOG OWNER INFORMATION
Full Legal Name: ______________________________________________
Phone Number: _______________________________________________
Email Address: _______________________________________________
Current Address: _____________________________________________
Current Living Situation: ☐ Private Residence ☐ Assisted Living ☐ Skilled Nursing /
Medical Facility ☐ Hospice ☐ Other: __________
SECTION 2: DOG INFORMATION
Dog’s Name: ________________________________________________
Breed(s): ___________________________________________________
Age: _______________________________________________________
Sex: ☐ Male ☐ Female
Spayed / Neutered: ☐ Yes ☐ No ☐ Medically Exempt
Current Veterinarian / Clinic: ____________________________________________________________
Known Medical Conditions: ____________________________________________________________
Behavioral Considerations: ____________________________________________________________
SECTION 3: QUALIFICATION STATEMENT – Inability to Provide Daily Care (Non-Financial)
Reason(s) for assistance (check all that apply):
☐ Physical disability or mobility limitations
☐ Chronic illness
☐ Cognitive or neurological condition
☐ Terminal illness / end-of-life planning
☐ Relocation to assisted living or medical care
☐ Other significant non-financial hardship
Explanation: ________________________________________________
Condition expected to be: ☐ Temporary ☐ Long-term ☐ Progressive ☐ End-of-life
SECTION 4: VISITATION PREFERENCES
Preferred Visit Frequency: ☐ Weekly ☐ Bi-weekly ☐ Monthly ☐ Other: ________
Preferred Visit Location: ☐ Residence ☐ Medical / Care Facility ☐ Outdoor / Neutral
Special Requests or Limitations: ____________________________________________________________
SECTION 5: FINANCIAL & ELIGIBILITY DISCLOSURE
☐ I am not seeking assistance solely due to financial inability
☐ I agree to provide limited financial documentation if requested
☐ I understand eligibility is contingent upon [Organization Name] review
Pet Trust / Estate Plan: ☐ Yes ☐ No ☐ In Progress
If yes, please describe: ________________________________________
SECTION 6: EMERGENCY & LEGACY INFORMATION
Primary Emergency Contact (Name / Relationship / Phone): ____________________________________________________________
Secondary Contact (Name / Phone): ____________________________________________________________
Interested in Memorial / Legacy component? ☐ Yes ☐ No ☐ Unsure
SECTION 7: ACKNOWLEDGMENT & CONSENT
☐ I understand [Organization Name] will oversee all placement decisions
☐ I agree to cooperate with [Organization Name] staff and assigned re-homer
☐ I understand visitation schedules are subject to safety and feasibility
☐ I understand [Organization Name] may discontinue participation if concerns arise
☐ I understand this program does not transfer ownership unless documented
Signature: __________________________________________________
Printed Name: _______________________________________________
Date: _______________________________________________________
[Organization Name] INTERNAL USE ONLY
Eligibility Determination: ☐ Approved ☐ Pending ☐ Denied
Reviewed By: _______________________________________________
Date: ______________________________________________________
Notes: _____________________________________________________