Service Dog Training Application

Name

Street Address

Your Email

Preferred method of contact

Parent/ Guardian Name(s)

School Information

(if applicable)

School Street Address

How many hours per week are you in school?

Medical Information

(to be completed by parent or guardian if under 18)

Doctor's Name

Office Name (if applicable)

Doctor's Office Street Address

Doctor's Office Phone

Primary Diagnosis

Age at time of diagnosis

Secondary Diagnosis

Please describe the most significant symptoms of the illness and how it affects you:

Check all medical problems that apply to you:

ArthritisFaintingVisual ImpairmentAsthmaHigh Blood PressureHearing ImpairmentAlcohol or Drug DependencyHeart DiseaseSeizuresDiabetesStability ProblemsAllergiesPsychiatric ProblemsOther

Do you have any cognitive difficulties (such as memory problems, inability to concentrate, etc.)
that would affect your ability to manage a service dog?

YesNo

If so, describe:

Would any of your current medications impair your ability to manage a service dog or impact
learning how to work with your dog?

YesNo

If so, describe:

Do you anticipate future surgery or hospitalization for any reason?

YesNo

If so, describe:

Do you require the assistance of an aide or family member for daily living skills?

YesNo

If so, list the name, phone number, daily hours (with you), and responsibilities of each individual.

Are they willing to assist with the daily care of a service dog, if needed?

YesNo

How many hours per week are you in therapy?

What types of therapies are you currently involved in (including special programs in
school)?

Mobility Information

Is your mobility limited?

YesNo

If so, describe:

Do you use a wheelchair?

YesNo

If so, what type?

ElectricManual

Do you use any other mobility aids?

YesNo

If so, what?:

Will you want your dog to help support you while you are walking or getting up?

YesNo

If so, describe:

Is one side of your body stronger than the other?

YesNo

If so,

LeftRight

On which side would you want the dog to work most of the time? (Example: If you are right-handed,
it is common for the dog to be trained to work on your left so your right hand can be free from leash,
etc; however, this can change based on stability needs, etc.)

LeftRight

Why?:

Are you restricted in the use of your hands or arms?

YesNo

If so, describe:

On a scale of 1-5 (1 = poor, 5= excellent), describe your:

Are you able to issue hand signals?

YesNo

Do you have spasms in your arms or legs?

YesNo

If so, how quickly do they pass?:

Do you bruise easily?

YesNo

Could a dog put his front legs up on your lap without hurting you?

YesNo

Are you able to issue voice commands in a clear, audible voice?

YesNo

Lifestyle Information

(to be completed by parent or guardian if under 18)

You currently reside in a:

HouseApartmentDuplexOther

If Other, please describe

Your residency currently has a

Fenced YardEnclosed AreaOther

If Other, please describe

With whom do you live?

Please list all other people living in your home.

Include: Name, Relation, Sex – M or F, Date of Birth

Have you ever owned a dog?
YesNo

Do you have any current pets?
YesNo

Include: Breed, Name, Age, Sex

Is anyone in your home allergic to dogs or pet dander?
YesNo

If so, describe:

Describe your typical daily schedule.

When do you get out of bed in the morning?

When do you retire in the evening?

On a scale of 1-5 (1 = low, 5= high), describe your:

Service Dog Requirements

(to be completed by parent or guardian if under 18)

Have you previously owned a service or assistance dog?

YesNo

If so, explain

Do you have any experience working with animals?

If so, explain

Describe the ways you believe a service dog can assist you.

After receiving your service dog, what are your hopes, goals, and fears?

Where will the dog exercise and have playtime?

Where will the dog be taken for toilet requirements?

How much exercise, on average, do you think a dog needs per day?

Describe your definition of exercise.

Additional Service Dog Help

Proximity to your home:

Do you have any concerns regarding owning a service dog?

YesNo

If so, describe.

Are you willing to participate in ongoing training sessions after receiving a service dog?

YesNo

Will your family accept a trained dog as an equal partner in your house?

YesNo

The information on this application is correct to the best of my knowledge. I understand that
this preliminary application is required to be eligible for an application package which will
determine my suitability for a service dog.

Your Initials:

Relationship to Applicant: