VSSN Veterans Support (need help?) Form
Requirements: A veteran or surviving spouse must have served honorably or is still serving in the military to recieve MOST support. Unfortuantely we do not provid financial aid or any type of monetary support.
Provide proof of service (VA Card, DD214, etc)
Currently be under the care of a physician or certified behavior health provider
Has a current diagnosed disabling condition
Resides or live in a condition that is deemed impoverished
Your location: City/State
Is someone helping you complete the form?
If you are not completing the form please state the name of the authorized person that can submit on your behalf and their title
First and Last of the Veteran or Military Service Member
Full Name of person applying for support
Type of Support Requested (check all that apply)
Food Vouchers/gift cards
Behavioral Health Counseling Services
Support or Companion Dog
Any allergies or conditions that we should consider
Are you looking for a service animal or companion animal?
The member in need is the
Active Duty or Rervist
Dependent (under 23 years old)
Adult dependent who is under the care of the veteran or service member
Tell us about the condition in which the support is needed: Please provide DD214 (REQUIRED), medical records or housing documentation, documentation of ongoing treatment or therapy (NOT REQUIRED) via email to
You must be 18 years old and sign as a sponsoring service connected family member in order to adopt a rescue animal. Release and Waiver of Liability PLEASE READ CAREFULLY.THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.This Release and Waiver of Liability (the “Release”) is executive at the time this form was submitted. By the person submitting this form and/or on the behalf of their minor as they are the parent or legal guardian. The Volunteer is in favor of Veterans Supplemental Support Network, also referred as VSSN and any other Veterans Supplemental Support Network, VSSN affiliated organization, and their respective directors, officers, trustees, employees, volunteers and agents (collectively, the “Released Parties”).I, the Volunteer, desire to work as a volunteer for one or more of the Released Parties and engage in the activities related to being a volunteer ("Activities"). I understand that my Activities may include but are not limited to the following: working in Veterans Supplemental Support Network, VSSN offices or special event venues/off site locations; traveling to and from work sites, or partnering locations, towns, cities or countries; consuming food available or provided; living in housing provided for volunteers; constructing and rehabilitating residential buildings; and other construction-related activities, as well as transporting goods and products.I, the Volunteer, hereby freely, voluntarily and without duress execute this Release under the following terms:Release and Waiver. I, the Volunteer, do hereby release and forever discharge and hold harmless the Released Parties and their successors and assign from any and all liability, claims and demands which I or my heirs, assigns, next of kin or legal representatives may have or, which may hereinafter accrue with respect to any bodily injury, personal injury,illness, death or property damage, which arises or may hereafter arise from or is in any way related to my Activities with any of the Released Parties, whether caused wholly or in part by the simple negligence, fault or other misconduct, other than intentional or grossly negligent conduct, of any of the Released Parties or of other volunteers.I understand and acknowledge that by this Release, I knowingly assume the risk of injury, harm and loss associated with the Activities. I also understand that the Released Parties do not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance in the event of injury, illness, death or property damage.Medical Treatment. I, the Volunteer, do hereby release and forever discharge the Released Parties from any claim or action whatsoever, which arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with my Activities with any of the Released Parties. I, the Volunteer, do hereby give permission for VSSN or Town Puppies to adminster or contact medical response team who may administer medication, first aid/cpr andor treatment in connection with a injury. If the Volunteer is less than 18 years of age, the Volunteer and the parents having legal custody and/or the legal guardians of the Volunteer (the “Guardians”) also hereby release and forever discharge the Released Parties from any claim whatsoever which arises or may hereafter arise on account of the decision by any representative or agent of the Released Parties to exercise the power to consent to medical or dental treatment as such power may be granted and authorized in a Parental Authorization for Treatment of a Minor Child.Assumption of the Risk. I, the Volunteer, understand that my Activities may include work that may be hazardous to me, including, but not limited to, the following: construction; loading and unloading; travel to and from the work sites or event venues; and exposure to lead, asbestos, and mold, which may cause or worsen certain illnesses, especially if I do not wear protective equipment, am exposed for extended periods of time, or have a preexisting immune system deficiency. I also understand there is some inherent risk in consuming local foods and living in local accommodations in the city(s) or country(s) visited. I further understand I may be traveling to and from locations where there is a risk of terrorism, war, insurrection, criminal activities, inclement weather or other circumstances that could threaten my health or safety. I also understand that it is the policy of the Released Parties not to pay ransom or make any other payments to secure the release of hostages.I hereby expressly and specifically assume the risk of injury or harm in the Activities and release the Released Parties from all liability for any loss, cost, expense, injury, illness, and death or property damage resulting directly or indirectly from the Activities.Insurance. I, the Volunteer, understand that, except as otherwise agreed to by the Released Parties in writing, the Released Parties are under no obligation to provide, carry or maintain health, medical, travel, disability or other insurance coverage for any Volunteer. Each Volunteer is expected and encouraged to obtain his or her own health, medical, travel, disability or other insurance coverage.Photographic Release. I grant VSSN and Partners full authorization and the absolute right and permission to record my appearance, performance, and voice, and to use, in an edited or unedited form, the results and proceeds thereof in connection with the photographing, filming, videotaping, and/or audio taping of my activities with VSSN and Partners.I understand that any photograph, film, video, audio tape, or other recording in which I appear will become the sole property of VSSN and Partners. I grant VSSN and Partners the absolute, worldwide, irrevocable, royalty-free right, in perpetuity, to adapt, annotate, assign, convey, copyright, display, distribute, modify, publish, release, reproduce, sell, transfer, or use photographic reproductions of me, audio reproductions of me, motion pictures of me, and/or videotape pictures of me, in any manner, in any media, including electronic computer media, for in which I may be included in whole, in part, or in composite, in conjunction with my own or any other picture, product, person or reproduction, in color or otherwise, made through any media at the studios of VSSN, Partners or elsewhere, for art, advertising, commerce, business, promotional, or trade or any other lawful purpose whatsoever. I also grant VSSN and Partners all right, title, and interest in any and all royalties, proceeds, or other benefits derived from such photographs, films, videos, audio tapes, or other recordings.I hereby waive any right that I may have to inspect or approve of the finished product or the advertising copy which may be used in connection therewith, or the use to which it may be applied.I hereby release, discharge and agree to hold harmless VSSN and Partners from any and all liability of any nature or description, which arises in connection with any use whatsoever of any image or audio recording of me, whether intentional or otherwise, and from any damage or injury that may result from any type of recording process or other action taken in furtherance of completion of the finished product, unless said use, recording, or other action is solely for the purpose of subjecting me to conspicuous ridicule, scandal, reproach, scorn and indignity.I agree that in the event, any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining clauses or provisions of this Release, which shall continue to be enforceable.Background Check. Veterans Supplemental Support Network, VSSN has the right to screen all potential staff (whether paid or unpaid), board members, applicant families and certain volunteers using the National Sex-Offender Registry and a criminal background check. By completing this form you are submitting to such inquiry. This cost is the responsibility of the Volunteer. Other. I, the Volunteer, expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the state where the Activities take place. I further agree that in the event any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining clauses or provisions of this Release, which shall continue to be enforceable. Further, a waiver of a right under this Release does not prevent the exercise of any other right.By clicking submit and checking this box, I express my understanding of an agreement with this Release; I sign here with a witness.Relationship: IMPORTANT: If the Volunteer is less than 18 years of age, all parents or guardians must also sign this Release and Waiver of Liability with a witness. Also, all parents or guardians must complete the “Parental Authorization for Treatment of, and Travel With, a Minor Child” on the following page. If only one parent or guardian executes this Release on behalf of a Volunteer who is under 18 years of age, then the undersigned parent or guardian of the Volunteer hereby covenants, warrants, represents and agrees that he or she is executing this Release on behalf of, and as an agent for, any other individual who may be a parent or guardian of the Volunteer, and that by executing this Release, the undersigned is binding himself/herself, the Volunteer, and any other parent or guardian of the Volunteer, and all of their heirs, executors, personal representatives, assigns and estates to this Release. Host Affiliate Site: PARENTAL AUTHORIZATION FOR TREATMENT OF, AND TRAVEL WITH, A MINOR CHILD I,_, am the parent or legal guardian having custody of, a minor child. As such parent or legal guardian, I hereby authorize andappoint of said volunteer listed on this form and I am an adult in whose care the minor child has been entrusted or a duly authorized agent of Veterans Supplemental Support Network, VSSN International, Inc., as my agent to act for me with respect to my minor child and in my name in any way I could act in person to make any and all decisions for me with respect to my minor child, concerning my minor child’s personal care, medical treatment, hospitalization, and health care and to require, withhold or withdraw any type of medical treatment or procedure, including X-ray examination, anesthetic, medical or surgical diagnosis or treatment which may be rendered to my minor child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state in which treatment is sought. My agent shall have the same access to my minor child’s medical records that I have, including the right to disclose the contents to others.
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