Medical Alert Dog Application

Medical Alert Dog

USDApplies to cost of Medical Alert Dog

Credit Card

Apple Pay

Google Pay

Cash App Pay

Name

First NameLast Name
Birthday of Recipient*

MonthDayYear
Date
Guardian Name if Under 18 *

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email of Beneficiary *
example@example.com
Email of Guardian
example@example.com
Phone Number of Beneficiary *
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number of Guardian
Please enter a valid phone number.Format: (000) 000-0000.

What will your Medical Alert Dog be Trained for? *
If Not Glycemic related illness or disability. Please describe your situation in as many words as needed.
Are you able to feel when you’re low?
Have you ever been in DKA
Date of Diagnosis *

MonthDayYear
Date
Current A1C *
Are you able to wake up in middle of the night?
Guardian if you wake the beneficiary up please let us know.
Do wear a Constant Glucose Monitor? *
If no, please explain why?
What Brand of CGM do you wear?
If you don’t wear a CGM put N/A
If not wearing a CGM would you be willing to during Transition Training?
Have you discussed a Medical Alert Dog with your Doctor
If no, explain why?

If Child is under 15 years of age, we will need additional details are you willing to do so?
If not put do not apply in all following questions on this page.
Does this child reside in a Multiple homes or reside in one home.
No, need to explain. This question is pertinent to training only.
Does this Child have any other needs besides Medical History Above?
Any other information we may need to know in respect to the Child?
Guardian are you aware you are responsible for exercise and health of Medical Alert Dog?
List all hobbies.

If above Beneficary is over 15 we have several questions if you would answer them honestly?
If not willing to answer put does not apply
Are you the beneficiary aware of this application process and looking forward to receiving a Medical Alert Dog?
Are you willing to exercise your Medical Alert Dog at minimum 4 days a week?
Are you aware you will be made responsible for this Medical Alert Dog?
Have you previously worked with a Professional Dog Trainer?
Have you been involved in the research of this Medical Alert Dog
If no, explain why?
List all hobbies.

Please describe a typical day for the beneficiary
Is the Beneficiary Allergic to Dogs and if so can you provide an Allergy Test proving such?

50% down 50% time of delivery6 equal payments over course of deliveryInstallment optionOther financing
If the Waiting List is open today are you ready to move forward?
If not when?
Did you have any further questions?

CedarOak Kennels LLC,

appreciates you for taking the time for filling out this Application Process. Please allow our team adequate time to respond to your application as we receive many. We are a for profit business and we hope to serve as many of our potential clients as possible! This Application is not a contract, however, after we sign a "Waiting List Contract" or "Medical Alert Dog Contract" you are then in a contract agreement with CedarOak Kennels LLC. The $50 Fee of application will be applied to the overall of cost Medical Alert Dog if you are selected. This Application is for Medical Alert Dog Information only and will be treated with HIPPA protocols. This Application form is through jotform.com (.) CedarOak Kennels LLC and any representative of such entity is not responsible for the security or actions of Jotform.com (.) If you or any party applicants are uncomfortable sharing this application online please print and submit by mail to 7330 LL road Red Bud IL, 62278
I agree to the above information is accurate and read the appreciation letter. *

Clear

Have you read the entire website? *
How much do you feel a Trained Medical Alert Dog should cost? *
This is for research only and will not determine if you are eligible for a Medical Alert Dog.
Do you follow our Instagram Page? *