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.

Name*
Title First Last
Date of birth*

Day
Month
Year
Address*
Street Address Address Line 2 Suburb State Post code Country
Home phone
Mobile phone
Do you have an email address?*
- Yes
- No
Email address*
EMERGENCY CONTACT - Name*
Title First Last
Relationship to you*
Address of emergency contact
Street Address Address Line 2 Suburb State Post code Country
Contact number of emergency contact*

Note that your emergency contact number should be a different number to your own.
Email of emergency contact

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
Do you have pets?*
- Yes
- No
Pet 1 - Name*

Please only enter 1 pets details, there will be space to enter a extra if needed.
Pet 1 - Type of animal*
Pet 1 - Breed*
Pet 1 - What colour is your pet? Any special markings?*
Pet 1 - D.O.B/Age*
Pet 1 - How long have you had your pet?
Pet 1 - Male or Female?*
- Male
- Female
Pet 1 - Is your pet desexed?*
- Yes
- No
- Unknown
Pet 1 - Is your pet microchipped?
- Yes
- No
- Unknown
Pet 1 - Your pets microchip number (if possible)
Pet 1 - Who is your current Vet?
Pet 1 - Vet name
Title First Last
Pet 1 - Vet phone number
Pet 1 - When is your pet's next vaccination due?

Please present a Vaccination Certificate when using the S.T.E.P.S. Feature of Golden Hearts™
Pet 1 - Do you give your pet a heart worm/intestinal worms tablet monthly or a vaccination yearly?
Pet 1 - Do you tick and flea treat your pet?
Pet 1 - Describe your pet's behaviour with other dogs
Pet 1 - Describe your pet's behaviour with other cats
Pet 1 - Describe your pet's behaviour with children
Pet 1 - Please describe your pets behaviour with strangers and going to new places
Pet 1 - Does your pet like to guard their food, toys or bed etc.?
Pet 1 - What is your pet's usual food/diet and how often does your pet eat daily?
Pet 1 - Where does your pet usually sleep?
Pet 1 - Does your pet have a favourite toy? If so, what is it?
Pet 1 - Does your pet have any special routines?
E.g. treat before bed, toileting before bed etc
Pet 1 - Is your pet comfortable with being left alone for short periods of time?
Pet 1 - Describe your pet's usual exercise routine and frequency
E.g. walks, playtime, catch, fetch, etc.
Pet 1 - Is your pet prone to bite or scratch? If so, please explain circumstances
Do you have a second pet to add?
- Yes
- No
Pet 2 - Name
Pet 2 - Type of animal
Pet 2 - Breed
Pet 2 - Colour/Markings
Pet 2 - D.O.B/Age
Pet 2 - How long have you had your pet?
Pet 2 - Male or Female?
- Male
- Female
Pet 2 - Is your pet desexed?
- Yes
- No
- Unknown
Pet 2 - Is your pet microchipped?
- Yes
- No
- Unknown
Your pets microchip number (if possible)
Pet 2 - Your pets microchip number (if possible)
Pet 2 - Who is your current Vet?
Pet 2 - Vet name
Title First Last
Pet 2 - Vet phone number
Pet 2 - When is your pet's next vaccination due?

Please present a Vaccination Certificate when using the S.T.E.P.S. Feature of Golden Hearts™
Pet 2 - Do you give your pet a heart worm/intestinal worms tablet monthly or a vaccination yearly?
Pet 2 - Do you tick and flea treat your pet?
Pet 2 - Describe your pet's behaviour with other dogs
Pet 2 - Describe your pet's behaviour with other cats
Pet 2 - What is your pet's usual food/diet and how often foes your pet eat daily?
Pet 2 - Describe your pet's behaviour with children
Pet 2 - Does your pet have a favourite toy? If so, what is it?
Pet 2 - Does your pet have any special routines?
E.g. treat before bed, toileting before bed etc
Pet 2 - Is your pet comfortable with being left alone for short periods of time?
Pet 2 - Is your pet prone to bite or scratch? If so, please explain circumstances
Pet 2 - Please describe your pets behaviour with strangers and going to new places
Do you have a third pet to add?
- Yes
- No
Pet 3 - Name
Pet 3 - Type of animal*
Pet 3 - Breed*
Pet 3 - What colour is your pet? Any special markings?*
Pet 3 - D.O.B/Age*
Pet 3 - How long have you had your pet?
Pet 3 - Male or Female?
- Male
- Female
Pet 3 - Is your pet desexed?
- Yes
- No
- Unknown
Pet 3 - Is your pet microchipped?
- Yes
- No
- Unknown
Pet 3 - Who is your current Vet?
Pet 3 - Vet name
Title First Last
Pet 3 - Vet phone number
Pet 3 - When is your pet's next vaccination due?

Please present a Vaccination Certificate if using the S.T.E.P.S. program of Golden Hearts™
Pet 3 - Do you give your pet a heart worm/intestinal worms tablet monthly or a vaccination yearly?
Pet 3 - Do you tick and flea treat your pet?
Pet 3 - Describe your pet's behaviour with other dogs
Pet 3 - Describe your pet's behaviour with other cats
Pet 3 - What is your pet's usual food/diet and how often foes your pet eat daily?
Pet 3 - Describe your pet's behaviour with children
Pet 3 - Does your pet have a favourite toy? If so, what is it?
Pet 3 - Does your pet have any special routines?
E.g. treat before bed, toileting before bed etc
Pet 3 - Is your pet comfortable with being left alone for short periods of time?
Pet 3 - Is your pet prone to bite or scratch? If so, please explain circumstances
Pet 3 - Please describe your pets behaviour with strangers and going to new places
Do you have a fourth pet to add?
- Yes
- No
Pet 4 - Name
Pet 4 - Type of animal*
Pet 4 - Breed*
Pet 4 - What colour is your pet? Any special markings?*
Pet 4 - D.O.B/Age*
Pet 4 - How long have you had your pet?
Pet 4 - Male or Female?
- Male
- Female
Pet 4 - Is your pet desexed?
- Yes
- No
- Unknown
Pet 4 - Is your pet microchipped?
- Yes
- No
- Unknown
Pet 4 - Who is your current Vet?
Pet 4 - Vet name
Title First Last
Pet 4 - Vet phone number
Pet 4 - When is your pet's next vaccination due?

Please present a Vaccination Certificate if using the S.T.E.P.S. program of Golden Hearts™
Pet 4 - Do you give your pet a heart worm/intestinal worms tablet monthly or a vaccination yearly?
Pet 4 - Do you tick and flea treat your pet?
Pet 4 - Describe your pet's behaviour with other dogs
Pet 4 - Describe your pet's behaviour with other cats
Pet 4 - What is your pet's usual food/diet and how often foes your pet eat daily?
Pet 4 - Describe your pet's behaviour with children
Pet 4 - Does your pet have a favourite toy? If so, what is it?
Pet 4 - Does your pet have any special routines?
E.g. treat before bed, toileting before bed etc
Pet 4 - Is your pet comfortable with being left alone for short periods of time?
Pet 4 - Is your pet prone to bite or scratch? If so, please explain circumstances
Pet 4 - Please describe your pets behaviour with strangers and going to new places
If you have more than 4 animals, please fill out the below text box with as much information as possible about your pet
Are you looking for a pet?
- Yes
- No
What type of pet would you be interested in?
- Dog
- Cat
- Other
If other, please specify
How old would you like your new pet to be?
- 0 - 2 years
- 3 - 7 years
- 8 years and older
Do you live in a
- House
- Apartmnet
- Complex
- Retirement Village
Does your house have a secure front gate?
If you live in an apartment please tell us what floor you live on and if you have elevator access
If you live in a complex, retirement village, or rental, are pets allowed?
Are you able to provide a pet exercise?
Do you have access to your own transport?
Short Term Emergency Pet Care Service (S.T.E.P.S.) preferences
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:
- Option 1: I would like to nominate an individual to care for my pets in an emergency
- Option 2: I would like to utilise AWLQ's rehoming program
Details of individual you would like to care for your pet
Full name Relationship to you Phone number
Golden Hearts Foster Carer
- Yes I am interested in becoming a Golden Hearts short-term emergency foster carer to help others who have gone into hospital with no-one to look after their pet
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.
I'm interested in fostering the following animals:
- Dog
- Cat
Notes/Additional Information

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:*
- I agree that the person I have listed as my emergency contact person has the authority to make decisions in relation to my pet on my behalf in the event that AWLQ is unable to contact me. I agree that I am financially responsible for any decision made by my emergency contact person, that incurs an expense to AWLQ which is not covered by my membership to the Golden Hearts™ Seniors’ Pet Support Program and I agree to reimburse AWLQ in the event of any such expense. I will not hold AWLQ responsible for any decision made by my emergency contact person which may be different from the decision I would have made.
*
- I agree that all the information I have provided to AWLQ in relation to my pet(s) or my needs is correct and accurate to the best of my knowledge. I acknowledge that if I have not provided AWLQ with correct or accurate information, that this could hinder AWLQ’s ability to care for my pet(s) or assist me with my needs in relation to a pet. I understand and agree that emergency boarding of my pet(s) in the S.T.E.P.S program is only for emergencies or hospital care where no-one else is able to help. I understand if my pet has serious health or behaviour issues that require specialist attention or management, they may not be eligible to qualify for the S.T.E.P.S. program.
*
- To the extent permitted by law and except to the extent a claim is caused or contributed to by the negligence, willful default of unlawful act or omission of AWLQ or any of their personnel, I release, discharge and indemnify AWLQ and its personnel from and against any claim which may be brought against or made upon or incurred by any of them in connection with the performance of this agreement and in relation to any program provided by AWLQ.

Golden Hearts Application

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

Pets Information