T.A.P. Assistance dog Application Form

Your full name

First NameLast Name

Your full address including postcode

Street Address

Street Address Line 2

City

Postcode

Phone Number

Area codePhone Number

Email Address

Childs full name including any middle names

Childs date of birth

Childs diagnosis (brief description)

Does your child receive DLA (disability living allowance)?

How many people are within your household? Please state childrens ages.

What is your landlord's pet policy?

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?

If you answered "Yes" please provide a detailed description:

Are there any other pets at your home address? If so, please tell us what they are and how many.

If you have to leave home, in case of an emergency or planned, where would your dog stay?

Areas in which your child would benefit from an Assistance dog?

Does your child require the use of any aids? (ie wheelchair, splints, helmets etc)

Are you able to give the dog walks and exercise?

Do you have a safe, secure and enclosed garden area?

Can you travel to training sessions when required to do so? (training is located in Fleet or Berkshire

Can you fully commit to keeping up with the dogs training schedule at home?

At any stage throughout the day or night will the dog be left alone? (ie for work etc)

If your application is successful you understand that you will be fully responsible for any vet treatment, food, flea and worming treatment.

Do you agree once the dog is working in public that it is your responsibility to purchase public liability insurance?

Do you agree and consent to T.A.P. Assistance dogs using photos of your child and dog for further fundraising efforts?

If you are unsuccessful with your application would you like to be considered at a later stage?

The date the form was completed and sent to T.A.P. Assistance dogs.

Signature of Potential Pup Parent