Apply For A Service Dog

Service Dog Application

Name *

First

Middle

Last

Email *

Phone Number *

Alternate Phone Number

Date of Birth *

Gender *

Name of Parent / Guardian (If Applicable)

Street Address *

City *

State *

Zip Code *

Employer

Occupation

What is your disability? Please explain. *

How long have you been disabled? *

Which 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? *

Do you use corrective lenses? *

Please mark any of the following that fit your needs due to hearing. *

Hearing Aid
ASL
Other
No Needs

Please rate your learning ability on a scale of 1 to 10. *

How do you handle routine medications? *

By Yourself
Assisted
Provided by Others

How do you handle your finances? *

By Yourself
Assisted
Provided by Others

How do you handle house cleaning? *

By Yourself
Assisted
Provided by Others

How do you handle meals? *

By Yourself
Assisted
Provided by Others

How do you handle getting dressed? *

By Yourself
Assisted
Provided by Others

How do you handle shopping and groceries? *

By Yourself
Assisted
Provided by Others

How do you handle personal care? *

By Yourself
Assisted
Provided by Others

Describe 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? *

Do you rely on a friend, family member, or attendant to transport you? *

Do you take a bus? *

Do you use cabs? *

Do you use Uber / Lyft / Transportation Service mobile apps? *

Do any other members of your household have a physical or mental disability? *

What 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? *

If 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? *

What pets do you have now? Describe type and age. *

Veterinarian's Name

Veterinarian's Office

Veterinarian's Phone Number

If your present dog is not well-mannered, are you willing to train your dog before you receive your service dog? *

If 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? *

Will it be difficult for you to limit your calendar for the 30-Day bonding period? *

Will it be difficult for you to attend an approved Obedience Class? *

Please 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. *

If 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. *

If 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. *

If 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. *

If 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. *

If 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. *

If 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. *

If 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. *

If 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. *

If no, please explain.

Do you agree to the following: That you must pay for grooming (or groom) your service dog once a month. *

If no, please explain.

Do you agree to the following: That you must pay all vet bills, including wellness checks. *

If no, please explain.

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