Senior Application

Seniors for Seniors Application

This questionnaire applies only to senior applicants interested in participating in PA Caring Hearts Seniors for Senior Adoption Program.
Please answer the following questions so that we can make a great match for you and your new animal companion. There are no wrong answers! Contact us if you have problems or questions in filling out this questionnaire.

Seniors for Seniors Application
Fields marked with an * are required

General Information 
Best Time to Call *
How would you describe your energy level? *
Are you filling out this questionnaire yourself? *

If not, please provide the following information about the person who is assisting you:
Who should be our primary contact regarding this questionnaire?


What Brought You To PA Caring Hearts? 
How Did You Hear About PA Caring Hearts? *
If Referred, What relationship does this person have to PA Caring Hearts?

Your New Animal Companion
I prefer a: *
I prefer a: *
Dog/Cat Size Preference: *

Living Situation
Are there any children (under 18) living in your home? *
Do you have a caregiver? *

If so, please provide:
Do you rent or own your home? *
Would you allow a Caring Hearts representative to visit your home? *

Current Animals Living in Your Home
Have you ever given up a dog or cat? *

Emergency Contact

Please provide an emergency contact:

Additional Comments

Certification