Service Dog Training Application Best Dog Daycare in Pottsville, AR Name Street Address City & State Zip Code Home Phone Cell Phone Other Your Email Preferred method of contact Date of Birth Sex MaleFemale Height (Feet & Inches) Weight (LBS) Parent/ Guardian Name(s) School Information (if applicable) School Name PublicPrivateOther School Street Address City & State Zip Code School Office Phone School County School District 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 City & State Zip Code 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: Upper body strength: Range of motion: Grip strength: Dexterity: 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 1) 2) 3) 4) Have you ever owned a dog? YesNo Do you have any current pets? YesNo Include: Breed, Name, Age, Sex 1) 2) 3) 4) 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: Activity Level: Anxiety: Independence: Time Outside House: Busyness of daily schedule: 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 Who will help you with the dog’s care if you are sick and cannot get outside: Name: Phone: 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: Applicant Name: Date: Relationship to Applicant: Δ Dog Daycare, Boarding & Training in Pottsville, AR. Hours of Operation Mon - Fri 7am - 6pm Sat & Sun 9am - 3pm Contact Us Call Us: (479) 777-0974 E-Mail Us: Click Here 606 Edwards Rd. Pottsville AR.