Service Dog Program Application

Have you read and understand all of the above requirements?

I have all of the required documents.

Please tell us what types of assistance you hope to receive from a service dog (include any and all desired tasks) and what having a service dog would mean for your quality of life.

Please tell us about your disability (be specific, list all conditions), including how it impacts your day to day life.

How long have you been diagnosed with these condition(s)?

Have you ever had a service dog before? If yes, what were they trained to do?

Who will be responsible for providing day to day care (feeding, walks, training, etc) to your service animal? Check all that apply.

Please tell us about who owns your primary residence:

Please tell us about your current employment. Where do you work? How long have you been employed there?

Please briefly describe your occupation. What are your daily tasks? What is your work environment like?

Do you plan to bring your service dog to work with you at this place of employment?

If you are unemployed, please share how you currently provide for yourself and how you would provide for a dog's needs.

If you’re not currently employed, are you planning to look for new employment once you have the support of a service animal?

Are you currently a student? Do you attend classes in person or online? Do you plan to bring your service animal to school with you?

Do you use any medical devices including but not limited to: Wheelchair, Crutches, Cane, 3-wheel Electric Scooter, Sip and Puff, Adaptive Language Device, Headgear, Breathing or Feeding Tubes, Other:

What form of transportation do you use? How often do you use it? (Personal Vehicle, Public Transportation (Bus or Light Rail), Taxi Service, Access-A-Ride, Other)

Please share with us links to any social media pages you'd like to share to help us get to know you better.

Please provide the names, contact numbers, ages and relationships of any adults living in the household with you.

Housecleaning

Meal preparation

Dressing

Bathing

Shopping

Caring for children

Remembering to take medications

Opening doors

Sleeping

Retrieving items (if so what type of items)

Being out in public/leaving the house

Managing my condition (if so please explain in detail)

Do you have an individual (be it family, friend, or hired assistants/caretakers) that assist you with your occasional or day to day life? If so, please provide information as to how often and for what tasks they assist

Please check any areas of the body in which you have any physical weakness or impairment (even if it is not related to your disability or the dog's tasks):

Please indicate if you have any previous amputations, injuries, or impairments that cause difficulty with your physical ability to perform your day to day activities:

Your Risk of Falling

Are you able to catch yourself if you fall?

Are you able to get up on your own after a fall?

Are you able to call for help when needed if you fall?

Is anxiety a contributing factor to the challenges you face with your day to day life?

Is depression a contributing factor to the challenges you face in day to day life?

What types of therapies and/or programs have you attended in the past? What were they addressing? What do you feel helped and did not help with any of them?

Are you currently receiving any therapies or programs? If yes, what are they are for how long will you be attending?

How do you deal with your anger and stress?

Please list the most common triggers for your anxiety or stress.

Please describe how you think a service animal may help with your anxiety, depression or mental health.

Dog's Name

Dog's breed/mix

Dog's age

What shelter or rescue was your dog adopted from?

How long have you had the dog?

Are you having any issues with your dog getting along with children, other pets or other household members in your home?

Has your dog every shown reactivity (barking, lunging, growling or biting) towards people?

Has your dog ever shown reactivity (barking, lunging, growling or biting) towards other dogs?

Are you having any other behavior concerns with your dog at home such as issues with housebreaking, separation anxiety or destructive behavior?

Are you currently having difficulties physically controlling your dog on walks or out in public?

Are you currently struggling to provide day to day care for your dog (walking, feeding, etc)?

Are you currently struggling to provide for your dog financially?

Is your dog spayed or neutered?

Is your dog currently up to date on their vaccines?

Please attach a copy of the written script from your physician detailing your need for a service dog.

Please attach a copy of the adoption paperwork for your dog.

Please attach a copy of your dog's current vaccination records.

Please attach a copy of your government issued photo ID.

I understand and consent to the above terms of the program.

I give consent for the completion of a background check as part of my application process.