Application for an
Assistance/Service Dog
Instructions: Print
this form and send it to Dogs in Service by mail or FAX
(908-236-8883)
Date: ____________________
About You:
1) Name:
_____________________________________________________________
Address:
______________________________________________________________
______________________________________________________________
Home telephone:
_______________________________________________________
2) Business Name:
______________________________________________________
Business telephone:
_____________________________________________________
Occupation:
___________________________________________________________
3) Brief history of your
disability: __________________________________________
______________________________________________________________
______________________________________________________________
4) Please describe your upper
body strength, particular emphasis on your arms and hands:
______________________________________________________________
______________________________________________________________
5) Do you have any other
physical limitation such as sight or hearing loss that we should
consider when choosing a dog for you?
_____________________________________________________________
6) Name of your physician:
_____________________________________________
Address:
____________________________________________________________
_____________________________________________________________
Phone Number:
_______________________________________________________
7) Do you use a mobility aid
(crutches, cane, walker, wheelchair)? _____________
8) Names and addresses of three
people who have known you more than five years and with whom you
are still in close contact:
1)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
2)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
3)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
9) Have you ever had a dog
before (as an adult)? ___ Do you have one now? ___
10) Do you have other pets?
_____ If so, what kind(s): _____________________
11) Would you take your dog to
work, school, social activities? _________
If not, where would the dog
be?__________________________
How many hours per day would
the dog be alone? ______________
12) Do you travel frequently?
_____ Would you take the dog with you? ________
13) Reasons why you want a dog:
_______________________________________
_____________________________________________________________
_____________________________________________________________
About Your Living
Arrangements:
1) Do you live in the (circle)
City Suburbs Rural ?
2) Names of everyone and ages
(if under 18) of all others living in your household:
Name:
____________________________ Age(under 18): _______
Name:
____________________________ Age(under 18): _______
Name:
____________________________ Age(under 18): _______
Name:
____________________________ Age(under 18): _______
Name:
____________________________ Age(under 18): _______
Name:
____________________________ Age(under 18): _______
3) Do you employ a personal care
attendant? _____
If yes, what hours do they
assist you?______________________
4) Are you, your personal care
attendant, or is anyone living in your household,
allergic to dogs? _______
5) Do you live in a
house/apartment/complex and is it one or more than one level?
____________________________________________________________
6) Do you have a fenced yard?
________________
7) Do you (or people in your
household) have many visitors?_______________
8) What are your hobbies or
other interests? ______________________________
____________________________________________________________
9) What types of transportation
do you use (bus, car, train, van etc.)_________
____________________________________________________________
10) Do you have any other
physical limitation such as sight or hearing loss that we should
consider when choosing a dog for you?
_____________________________________________________________
Dog Training
All dogs are taught basic dog
obedience and are socialized in public situations. What tasks do
you want your dog to accomplish for you? Put an "x"
next to the tasks which interest you.
_____ Provide balance for
you when you walk
_____ Pick up dropped
objects
_____ Retrieve objects off
of counters or tables
_____ Turn light switches on
and off
_____ Open and close doors
in your home
_____ Carry a backpack for
you
Other tasks you would like us to
consider training your dog to do:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Can you arrange to take time off
from work/school/family to come to our facility in New Jersey for
three weeks to train with your dog?
______________________________________________________________
Please draw a simple sketch of
the layout of the rooms in your home (kitchen, bedrooms, living
room, bathrooms):
Please tell us anything else
about yourself that you think will help us to select the proper
dog for you:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
I certify that the above
statements are true to the best of my knowledge.
I understand that a dog needs
daily training and attention. The dog will need physical exercise
each and every day and grooming at least once a week. The dog
will require annual veterinary care as well as veterinary care as
needed. I am able and willing to provide these things for the
dog.
I understand that, at any time
and for any reason, if I am unable to continue to own and care
for the dog that he/she will be returned to Dogs In Service.
_____________________________________________________
Signature of applicant
___________________________
Date
The
Barker Lounge for their incredible generosity in fundraising for us.
Their hard work will help us with all of our programs.
FAX 908-236-8883 