Service Dog Program - Initial Application for Consideration

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Phone Number

Please enter a valid phone number.

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address (if different than physical address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you find us? Who referred you?

Is the service dog for someone who is over 18 years old?

Yes, it is for me and I am over 18 years oldYes, it is not for me although both myself and the potential dog handler are both over 18 years oldNo, it is for me and I am not over 18 years oldNo, it is for my child but I will be the responsible party

Person's living in your home & their relationship to you (please list ages for children as well):

Please list all the animals in your home (species, names, ages, breeds, sex)

Based on the ADA's Definition of Disability as stated above, are you legally disabled?

Only if you are comfortable, please share with us a very brief overview of your disability/disabilities.

If you are accepted into our service dog program we will ask for contact information for your support team, including doctors, therapist, family and/or friends who will be a part of your journey with your service dog.

Is everyone in your household or immediately family/life supportive of your desire to train a service dog?

Please begin considering a list of your support team that we may contact should we have concerns for your health or well being at any point in time. This list will be required upon acceptance into the service dog program.

Have you discussed with your doctor(s) that you are considering getting a service dog and are they supportive of the idea?

If you are accepted into our service dog program we will get further details about how a dog will aid you throughout life however if you are comfortable, please share with us any details about your disabilities that will be relevant to working together to train a dog.

Only if you're comfortable, please share with us details about how you think a dog can help with your disabilities.

Have you ever had a service dog before?

Can you tell us about your experiences in dog training?

Can you give us an idea of what your weekly schedule looks like:

Please give us an idea of what type of time commitment you are able to make to training a dog:

Please give us a brief overview of your life's routines. Include routine places you visit that a service dog would be expected to join you. (i.e. gym, work, school, grocery shopping, driving trips, trips by airplane, etc...)

Please check all that apply:

I have an adult dog (over 1 year old) that I would like to train to be my service dogI have a puppy (under 1 year old) that I would like to train to be my service dogI have put a deposit down on a puppy from a breederI would like help finding an appropriate breeder for a service dog puppyI would like to rescue a dog to train into my service dogI am unsure of what path I should take and do not currently have a dogOther

Dog Name:

Dog Age/Sex/Breed:

Date the dog joined your household:

Where did the dog come from?

What Veterinarian do you use for your dog's routine care?

Date of last physical exam by a Veterinarian:

Date of last blood work:

Is your dog/puppy up to date on exam/vaccinations/recommendations by your Veterinarian?

Any health conditions or medications?

Any allergies or food sensitivities?

Please describe any training along with details about the training that you've done with this dog:

Type a question

Please upload a photo or PDF of your dog's current Rabies Vaccination. If you have trouble uploading this please email us at info@behaviortails.com or give us a text/call at 828-565-1050 for help

Upload a cute photo of your dog

Do you have any specifics about what type/size of dog you are looking for?

Can you give us some information about why you've picked that type of dog or details about what you're looking for:

Do you have any restrictions for a dog based on breed? size? Hair coat? Behavior?

Any limitations on breed? Breeder? Location? Timeline?

The name of your breeder:

Breeder website:

Date puppy joins your family:

Puppy's Age when they joined your family:

Please give details about what socialization your puppy will receive or did receive while at the breeder:

What socialization have you done since your puppy has come home?

The person signing this form must be over 18 years of age and the legally responsible party for this animal and by submitting this form they are agreeing that all the information listed is accurate and that you have disclosed any history of aggression or injury that has been caused by the dog.

Today's Date:*

Date

Signature*

Behavior Tails, LLC