Application

Thank you for completing the application for a Service Dog.
The addition of a service dog into a person's life is a big commitment. The benefits, both physical and emotional, are significant.
Once your application has been reviewed, an initial interview will be scheduled to discuss the specifics of our program, and how a dog may fit into and benefit your life. We respect the privacy of applicants and all information is kept confidential.

Name

Birthdate

Parent or guardian if minor

Home Phone Cell Phone

Email

Address

City

State and Zip

Please tell us how you heard about us? i.e. friend (who?), Internet

What type of Service Dog are you interested in?
Diabetic Alert Dog
Mobility Support Dog
Autism Assistance Dog
PTSD Support Dog
Emotional Support Dog
Other type of Dog - Please specify

Have you ever owned a dog before?
Yes
No

Have you ever owned a service dog before?
Yes
No

Other than your service dog are you planning on obtaining any other animals within the next year?
Yes
No

Please explain your reason(s) for wanting a Service Dog

Please tell us the type of home you have i.e. apartment, single/multi level, high rise

Please list names and ages of adults and children that live in the home

Do you have stairs?
Yes
No

Do you have an elevator?
Yes
No

Do you have a yard?
Yes
No

If you have a yard is it fenced and secure?
Yes
No

Please describe the area that will be utilized for your dogs relief area (restroom)

Do you have a motor vehicle?
Yes
No

If you have a motor vehicle please provide make, model and year

Please describe public transportation that you use and how often, i.e. bus, subway, airline

Are you a student?
Yes
No

If yes please provide grade level, school address, principals name

Are you employed?
Yes
No

If yes please describe occupation and work environment i.e. office, factory, busy, noisy

Describe your lifestyle and activity level i.e. hobbies, sports, etc.

Do you have any of the following conditions?
Deafness / Hearing loss
Speech impairment
Vision impairment
Limited mobility
Muscular weakness
Memory loss
Allergies
Chronic pain
Heightened emotions
Depression
Attention deficit disorder
Hyper activity disorder
Skin sensitivity
Heat / cold sensitivity
Balance or coordination problems
Kidney disease
Kidney dialysis
Neuropathy
Retinopathy
Amputations
Other condition - Please specify

Do you use any of the following?
Glasses
Prosthesis
Leg brace
Wrist brace
Cane or crutch
Walker
Manual wheelchair
Electric wheelchair
Hearing aid

Are you or anyone in the household allergic to dogs?
Yes
No
If yes please describe who is alergic to dogs

Do you use tobacco products?
Yes
No

Does anyone in the household use tobacco products?
Yes
No

Please describe any dogs that live in the household or visit often.
Include age, breed, sex, and if they are spayed or neutered.
1.
2.
3.
4.
5.
6.

Please describe any other animals that live in the household or visit often.
(Cats, Rabbits, Chickens, Birds, Horses, Goats, etc.)

Please provide any additional information you feel is relevant

* * * * * IF YOUR ARE APPLYING FOR A DIABETIC ALERT SERVICE DOG * * * * *

At what age were you diagnosed as a Diabetic?

What was the date of your last A1c?

What was the result of your last A1c?

Type of diabetes?
Type 1 Type 2

Insulin dependent?
Yes No

Insulin delivery method?
Pump Injection

Do you use a Continuous Glucose Monitor (CGM)?
Yes No

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