Service Dog Application Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastEmail *Phone Number *Alternate Phone NumberDate of Birth *Gender *Name of Parent / Guardian (If Applicable)Street Address *City *State *Zip Code *EmployerOccupationWhat is your disability? Please explain. *How long have you been disabled? *Please indicate the devices that you use *Manual WheelchairPower WheelchairCrutchesCane3 Wheel Electric ScooterSip and PuffOtherWhich of the above devices do you use the most often? *Please rate how easily understood your voice is on a scale of 1 to 10. *Please rate the tone variation of your voice on a scale of 1 to 10. *Please rate the volume of your voice on a scale of 1 to 10. *Do you use a word board? *YesNoDo you use corrective lenses? *YesNoPlease mark any of the following that fit your needs due to vision. *Large FontAudioTapeNote TakerOtherNo NeedsPlease mark any of the following that fit your needs due to hearing. *Hearing AidASLOtherNo NeedsPlease rate your learning ability on a scale of 1 to 10. *How do you handle routine medications? *By YourselfAssistedProvided by OthersHow do you handle your finances? *By YourselfAssistedProvided by OthersHow do you handle house cleaning? *By YourselfAssistedProvided by OthersHow do you handle meals? *By YourselfAssistedProvided by OthersHow do you handle getting dressed? *By YourselfAssistedProvided by OthersHow do you handle shopping and groceries? *By YourselfAssistedProvided by OthersHow do you handle personal care? *By YourselfAssistedProvided by OthersWhat personal attendants (including family members) do you use? *Personal Care AideCookingCleaningMedicalOtherNo attendantsDescribe how many attendants you have, and how often they help you (Hourly / Daily / Weekly). *Please describe your limitations. (I.E. Mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, your ability to read and understand written material, and anything that might help us understand your needs.)What work, school, or rehabilitation program(s) have you completed?What is your current work or school schedule?Do you drive? *YesNoDo you rely on a friend, family member, or attendant to transport you? *YesNoDo you take a bus? *YesNoDo you use cabs? *YesNoDo you use Uber / Lyft / Transportation Service mobile apps? *YesNoDo any other members of your household have a physical or mental disability? *YesNoWhat are your plans for work or school? *List the people living in your home, including their ages and their relationship to you. *Please list any people living in your home who have any disabilities, and describe their disabilities and limitations. Please describe your home and yard.Is your yard fenced? *YesNoIf yes, how high is your fence?If your yard is not fenced or if your fence is too short or needs repair, will you be able to put up a secure fenced area before you receive your dog? *YesNoWhat pets do you have now? Describe type and age. *Veterinarian's NameVeterinarian's OfficeVeterinarian's Phone NumberIf your present dog is not well-mannered, are you willing to train your dog before you receive your service dog? *YesNoIf no, please explain why.What kind of dogs have you had before? *Have you ever re-homed a pet? If so, what was the reason? *On a daily basis, how will you handle the following: Walking, cleaning, feeding, medicating, exercising, and grooming for your service dog? *How will you handle the care of your service dog if you are hospitalized? *Will it be difficult for you to attend placement classes at Outreach Pawsabilities? *YesNoWill it be difficult for you to limit your calendar for the 30-Day bonding period? *YesNoWill it be difficult for you to attend an approved Obedience Class? *YesNoPlease explain any "yes" answer as it pertains to the 3 questions above.Do you agree to the following: There is a reasonable expectation that your medical situation will allow you to use and benefit from your dog's skills for 8 to 10 years. *YesNoIf no, please explain.Do you agree to the following: That a service dog will spend most of their time with their partner at home, work, school, and social events if he or she is certified for public access and that no service dog will be in a yard or kennel for long periods of time. *YesNoIf no, please explain.Do you agree to the following: That a service dog is not a family pet. He or she has a specific function in their partner's life and minimal interaction with others. *YesNoIf no, please explain.Do you agree to the following: That you and your dog are representatives of Outreach Pawsabilities as well as for the entire assistance dog industry (guide, hearing, and service dogs) and you will be expected to maintain your dog's appearance and manners, as well as your handling skills. *YesNoIf no, please explain.Do you agree to the following: That a service dog cannot be allowed off leash except in a secure area. Exercise and elimination must be done on leash or in a fenced yard or dog run. *YesNoIf no, please explain.Do you agree to the following: That you must assume full responsibility as caretaker of your service dog, in charge of their safety, health, and welfare. Their needs include medical care, nutritional care, and daily exercise and play. *YesNoIf no, please explain. Do you agree to the following: That you assume full responsibility for maintaining appropriate training and behavior, annually updating your ADI public access certifiaction or Canine Good Citizen certification as applicable. You must maintain identificiation for public access, if applicable. *YesNoIf no, please explain. Do you agree to the following: That you must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage caused by your dog. *YesNoIf no, please explain. Do you agree to the following: That you must provide one 34 lb dog food (whatever type is being used) each month. *YesNoIf no, please explain. Do you agree to the following: That you must pay for grooming (or groom) your service dog once a month. *YesNoIf no, please explain. Do you agree to the following: That you must pay all vet bills, including wellness checks. *YesNoIf no, please explain. PhoneSubmit