Intake Form

Contact Information
Application Type
Service Information
Medical Information
Living Situation & Animal Care
Supporting Documents
Please upload a valid file (JPG,PNG,PDF). Size of file should not be more than 5MB.
Please upload a valid file (JPG,PNG,PDF). Size of file should not be more than 5MB.
Please upload a valid file (JPG,PNG,PDF). Size of file should not be more than 5MB.
Please upload a valid file (JPG,PNG,PDF). Size of file should not be more than 5MB.

Rental agreement must contain applicants name and pet addendum.
Home ownership documentation must contain applicant’s name.
Please upload a valid file (JPG,PNG,PDF). Size of file should not be more than 5MB.
Applicant Survey
Shared Information Consent

Please read the Shared Information Consent Agreement in full and agree below:

By submitting this application I hereby give the Companions for Heroes (C4H) Staff, authority to use the information (including my participation in the C4H program, verbal testimonies, quotations, photos, emails, text messages or any communication of any kind) shared by me on this day (the application date) or any day thereafter in any corporation-related promotional material including the C4H websites, brochure, media, press releases, and merchandise.

I acknowledge and agree that C4H, or others operating on behalf of C4H may disclose to the public information that I provide to C4H or its agents, including my Protected Health Information ("PHI"). This PHI may include my name, birth date, address, telephone number, diseases and ailments, medical records and treatment information. This agreement to disclose applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, as amended, and under the rules and regulations thereunder, as well as applicable state law.

C4H may use and disclose the information provided, including PHI, for the business purposes of C4H, including but not limited to education, fund raising, advertisement of C4H, and support of other veterans and individuals who C4H assists.

With respect to (1) all video footage, photographs recordings, and written materials provided by me to C4H in connection with the Companions for Heroes program; and (2) all print, video, film, recordings and written materials prepared by C4H or its representatives in connection with the Companions for Heroes program in which I appear or am referenced, including, but not limited to, photographs, print materials, commercials, film or video, social media posts, posting on websites or webcasts ((1) and (2) of this paragraph shall collectively be referred to as "Works"), I hereby grant to C4H and its designees, including assignees and others that C4H collaborates with, the unrestricted, perpetual, worldwide right to reproduce, copy, modify, create derivative works and otherwise use, display, distribute, exhibit, transmit and broadcast the Works or any part thereof in any media, means or embodiment, now known or hereafter to become known, including my voice, image and identity without further approval or payment to me of any kind. I also hereby waives any right of inspection or approval of my appearance in the Works.

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