Form WDVA4709 "Pet Guideline Agreement" - Wisconsin

What Is Form WDVA4709?

This is a legal form that was released by the Wisconsin Department of Veterans Affairs - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2014;
  • The latest edition provided by the Wisconsin Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WDVA4709 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Veterans Affairs.

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Download Form WDVA4709 "Pet Guideline Agreement" - Wisconsin

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Wisconsin Veterans Home at King
Wisconsin Veterans Home at Union Grove
N2665 County Rd. QQ
21425 G Spring St.
King, Wisconsin 54946-0600
Union Grove, Wisconsin 53182
(715) 258-5586
(262) 878-5670
PET GUIDELINE AGREEMENT
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
Volunteer Name:
Pet’s Name:
Breed:
My pet is up-to-date with all vaccinations:
Yes
No
A copy of my pet’s current vaccinations has been given to the Volunteer Coordinator and will be attached to
this form:
Yes
No
As the owner of the above said animal, I understand and agree to the following:
• The home-like enjoyment that a pet brings to a facility cannot overshadow the clinical needs for some
formal policies and procedures to protect Resident’s health and safety. Pet visits are recognized as a
therapeutic intervention for the Members of the Wisconsin Veterans Home.
• Only clean, healthy pets that are up-to-date with all immunizations are allowed to be brought onto
Wisconsin Veterans Home (WVH) property. I will provide the Volunteer Coordinator with proof of my
animal’s vaccinations.
• I must accompany my pet at all times and keep my pet appropriately secured, leashed, or caged and
controlled at all times.
• My pet is not allowed in areas where food is being prepared, served or stored.
• My pet is not allowed on furniture in the common areas of the facility and may only be allowed on
furniture in Members’ rooms at the discretion of the Member.
• In order to bring an exotic pet (anything other than a dog, cat or rabbit) to the WVH, I must have
advanced approval by Administration (Activity Director, Volunteer Coordinator, Deputy Commandant
or Nursing Supervisor) during regular business hours.
• My pet must be properly housebroken and I will be responsible for providing all clean-up materials and
disposal of waste in outdoor receptacles.
• If my pet becomes stressed or unruly, or procedures are not being followed, I will be asked to leave the
WVH grounds.
• During my visit I will respect the rights of Members who are uninterested in or afraid of animals.
Volunteer Signature:
Date:
Volunteer Coordinator Signature:
Date:
WDVA 4709 (03/14)
Templates\WDVA_4709-Pet-Guideline-Agreement.dotx
Wisconsin Veterans Home at King
Wisconsin Veterans Home at Union Grove
N2665 County Rd. QQ
21425 G Spring St.
King, Wisconsin 54946-0600
Union Grove, Wisconsin 53182
(715) 258-5586
(262) 878-5670
PET GUIDELINE AGREEMENT
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
Volunteer Name:
Pet’s Name:
Breed:
My pet is up-to-date with all vaccinations:
Yes
No
A copy of my pet’s current vaccinations has been given to the Volunteer Coordinator and will be attached to
this form:
Yes
No
As the owner of the above said animal, I understand and agree to the following:
• The home-like enjoyment that a pet brings to a facility cannot overshadow the clinical needs for some
formal policies and procedures to protect Resident’s health and safety. Pet visits are recognized as a
therapeutic intervention for the Members of the Wisconsin Veterans Home.
• Only clean, healthy pets that are up-to-date with all immunizations are allowed to be brought onto
Wisconsin Veterans Home (WVH) property. I will provide the Volunteer Coordinator with proof of my
animal’s vaccinations.
• I must accompany my pet at all times and keep my pet appropriately secured, leashed, or caged and
controlled at all times.
• My pet is not allowed in areas where food is being prepared, served or stored.
• My pet is not allowed on furniture in the common areas of the facility and may only be allowed on
furniture in Members’ rooms at the discretion of the Member.
• In order to bring an exotic pet (anything other than a dog, cat or rabbit) to the WVH, I must have
advanced approval by Administration (Activity Director, Volunteer Coordinator, Deputy Commandant
or Nursing Supervisor) during regular business hours.
• My pet must be properly housebroken and I will be responsible for providing all clean-up materials and
disposal of waste in outdoor receptacles.
• If my pet becomes stressed or unruly, or procedures are not being followed, I will be asked to leave the
WVH grounds.
• During my visit I will respect the rights of Members who are uninterested in or afraid of animals.
Volunteer Signature:
Date:
Volunteer Coordinator Signature:
Date:
WDVA 4709 (03/14)
Templates\WDVA_4709-Pet-Guideline-Agreement.dotx