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Service Dog Training Application Form

Human information

Name

*

Email

*

Phone Number

*

Address

*

Service Background

*

Service Background

Active Duty

Veteran

Active First Responder

Former First Responder

Neither

Branch of Service/First Responder Duty

Years of Service

Are you currently diagnosed with a disability by a medical professional?

*

Select the tasks you need a service dog to preform. Choose all that apply

*

Select the tasks you need a service dog to preform. Choose all that apply

Deep pressure therapy

Interrupting dissociative behaviors

Guiding to exits or safe spaces

Alerting to oncoming anxiety attacks

Providing tactile stimulation

Retrieving medication or emergency phone

Waking handler from night terrors

Creating space in crowds ("blocking")

Retrieving dropped items

Opening/closing doors, cabinets, drawers

Pushing accessible buttons

Assisting with balance and stability while walking

Pulling a wheelchair short distances

Helping with dressing or undressing

Diabetic alert

Seizure alert or response

Cardiac alert

Allergen detection

Give brief list of your lifestyle activities. I.E going to the beach or walking in parks

*

Do you live in a House or Apartment?

*

Do you have a fenced in yard?

*

Dog Information

Do you already have a dog?

*

If you do not have a dog already, list the breeds you would prefer. List as many as you would like.

Dog's Breed

Dog's Age Years and Months

Dog's Sex

Vaccination Status

Up-to-date

Not-up-date

If not up to date, please explain why

Any significant medical history about your dog?

Please explain

Previous Training, check all that apply.

*

Previous Training, check all that apply.

Professional Obedience Training

Canin Good Citizen

Star Puppy

Canine Good Citizen Advanced

Canine Good Citizen Urban

Trick Training

Protection Sports

Tracking

Detection Training

None

Do you have any current pets?

*

Service Dog Training Application Form

Human information

Name

Email

Phone Number

Address

Service Background

Branch of Service/First Responder Duty

Years of Service

Are you currently diagnosed with a disability by a medical professional?

Select the tasks you need a service dog to preform. Choose all that apply

Give brief list of your lifestyle activities. I.E going to the beach or walking in parks

Do you live in a House or Apartment?

Do you have a fenced in yard?

Dog Information

Do you already have a dog?

If you do not have a dog already, list the breeds you would prefer. List as many as you would like.

Dog's Breed

Dog's Age Years and Months

Dog's Sex

Vaccination Status

If not up to date, please explain why

Any significant medical history about your dog?

Please explain

Previous Training, check all that apply.

Do you have any current pets?

List your current pets