Rescue Dog Adoption Application

APPLICATION REQUESTS

emBARK-sd
emBARk-sd is an all-volunteer, non-profit, organization dedicated to improving the quality of life for people with disabilities and emotional support needs by raising, loving, and training assistance dogs. emBARK-sd is completely funded through fundraising efforts and public donations. All of our pets are cared for by the Foundation and receive basic, advanced and service training as well as complete medical care, which includes worming, vaccinations, spaying/neutering and microchipping prior to their adoption.
This application is for both children under 14 years old and their legal Parent/Guardian. At this time, we are placing dogs within 50 miles of St. Louis. Please remember there are 3 members that make a service dog work. Parent/Guardian, child, and service dog. We generally only use Golden Retrievers and Labrador Retrievers. Only fully completed forms with all documents submitted will be considered. Anyone over 18 in the househould may be subject to a background check. We will need to conduct a home visit and verify that you will be able to finacially support the yearly average cost of a large dog, approximately $1500-2500.

There is a $35 non-refundable fee to process the application. All fields must be filled out for the application to be reviewed.

Please include a copy of a Physicians recommendation for a therapy/service dog.

Applications will not be considered if there is a cat in the home.
Child/Parent Information
Child's Name

First NameLast Name
Parent/Guardian Filling out Application

First NameLast Name
Relationship to Child?

MotherFatherOther
Parent/Guardian 2

First NameLast Name
Relationship to Child?

MotherFatherOther
Child's Date of Birth

MonthDayYear
Date
I acknowledge that everyone 18 years and older in the household may undergo a background screening?

YesNo
Anyone else in the household over 18?

YesNo
Other Person?

First NameLast Name
Relationship to Child?

MotherFatherOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Primary E-mail to be used for further communication:
How did you hear about the Foundation:
Character reference and phone number:
Medical Information
What is your child's primary diagnosis?
What specific tasks do you think a service dog could do to assist you and your child?
Physician Name:
Physician Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Number:

Area CodePhone Number
Does your physician recommend a Service Dog?

YesNo
Does your child see a ABA Therapist?

YesNo
If yes, can we contact?

YesNo
ABA Therapist Number:

Area CodePhone Number
What type of adaptive equipment does your child use? (wheelchair, crutches, hearing aid)
What type of medical treatment are they currently receiving?
If applicable, please include a copy of a Physician recommendation for a service/therapy dog.

Browse Files

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Employment Information
Is one Parent/Guardian employed?

YesNo
Employer Name:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number?

Area CodePhone Number
Can we contact your employer to verify employment?

YesNo
Household/Other Pet Information

Tallman Family Foundation can not home a service dog with other dogs in the house. It may affect the training and behavior of the service dog.
Is there a cat in the home?

YesNo
Do you live in a:

HouseApartmentCondoMobile HomeOther
If you rent, Landlord's name?

First NameLast Name
If you rent, what is your Landlord's phone number?

Area CodePhone Number
Are there any restrictions from your landlord or subdivision?

Number of petsSize or weight restrictionsBreed restrictionsNone
Do you have a fully fenced yard?

YesNo
Do you have any of the following?

Underground fenceKennelDog RunN/A
If you don't have a fence, how will you provide exercise for the dog?
Have your children been around animals before?

YesNo
Does anyone in your home have allergies to dogs or have asthma?

YesNo
Service Contract Information:

emBARK-sd requires that families maintain a high level of care with their service dog. It is expected that your dog will be fully up to date on all medical care, provided a high quality diet, maintain a healthy weight and be properly groomed. To accomplish this a family needs to be prepared to spent $1500-2500 each year.
Are you financially prepared to care for a service dog?

YesNo
Are you financially prepared to feed the dog (about $100-$150 a month)?

YesNo
Are you financially prepared to pay vet costs (about $300-500 a year)

YesNo
Are you physically able to bathe the dog?

YesNo
If no, are you financially prepared to pay for grooming?

YesNo
Additional Information:
What circumstances would lead you to give up your new dog?
If you had to give up your dog, what would you do with him/her?
If yes, where?
How did you find out about emBARK-sd?

GoogleAgencyFacebookFriend/Family MemberOtherOther
Anything else we should know?:
I understand that I assume full responsibility for the welfare of this pet from the date of taking the service dog home.

The Tallman Family Foundation reserves the right to deny services to any applicant which doesn't meet the criteria necessary for placement of a service dog or who requires services not trainable within the guidelines of the agency.

If we find any reason that the service dog is not being treated to the standards that we hold ourselves to, we reserve the right to re-home the service dog.

Additionally we may require more information.
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APPLICATION REQUESTS

Child/Parent Information

Medical Information

Employment Information

Household/Other Pet Information

Service Contract Information:

Additional Information: