Weeping Tree Kennels Service Dog Application

Weeping Tree Kennels Service Dog Application

File. 176, A. 20, P. 1-11
Part 1 - Starting Information:

Thank you for requesting a Service Dog application from W.T.K Service Dog Program. The addition of a Service Dog into a person’s life is a big commitment. The benefits, both physical and emotional, are significant. We encourage interested parties to apply for classes. This in no way commits the applicant to a decision, but instead indicates an interest and allows us to schedule an interview to discuss specifics of the program and how your dog may fit into and benefit the individual’s life.

It’s important that we learn about the applicant, so we ask that the person applying for the dogs training complete the application if possible. If unable to do so, please complete it using the applicants own words. In the case of children under 18, a legal guardian or caregiver is required to read, help fill out, and sign the applicant. If unable to do so, please reach out to a W.T.K representative to help either fill that spot or get cleared for filling out the form alone.

Once the application has been reviewed, an initial interview will be scheduled. W.T.K Service Dog Program respects the privacy of its applicants and recipients and all information is kept confidential between the Board of Directors.

W.T.K Service Dogs Program conducts its business and acceptance process in a manner that will not discriminate against anyone on the bias of race, religion, gender, national origin, age, any disabilities, sexual preference, life expectancy, or whether the individual is a veteran. It is W.T.Ks policy to treat everyone who comes in contact with our organization with respect and dignity at all times.
I have read, understand, and agree to this part of the application (initial):*
Guardian signature if applicant is under 18 (initial):

Part 2 - Applicants information:

If information is non applicable leave blank or mark “N/A”.
Name of Applicant*

First NameMiddle NameLast Name
Guardians name if user is under 18

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of applicant
Guardians phone number if applicant is under 18
Applicants email
example@example.com
Guardians email if applicant is under 18
example@example.com
Employment information:

What is/are the applicant's primary disability (disabilities)?*
What was the cause of said disability (disabilities)?*
Ie: Trauma (physical, mental), Born with it, developed over time, medical cause (accident, covid, ect).
Current:*

WeightHeight
Sex:*

MaleFemaleOther
Are you:*

SingleMarriedEngagedDivorcedOther
Please list all other Service Dog programs you've applied to and your current status with them:*
Answer N/A if non applicable.
Have you been denied by another program? If yes, why?*

Do you live:*

AloneWith guardian(s)With spouse/ partnerWith roomatesOther
Number of residents in house?*
You count as "1".
Age(s)?
Number of children (under18) in house?
Age(s)?
Do children often visit the residence? If so, what ages, and how often?
Do you have any animals in the residence?*

YesNo
Does your residence have a fence (ed in area)?*

YesNo
How many animals in residence?
Type and breed of animal(s)?
Gender(s)?
All altered?
All up to date on legally required veterinary care?
Any known issues involving animals that could affect a Service Dogs training? If so, what?

Please describe in detail what primary tasks you would need the Service Dog to preform:*

Please list your source of income:
Do you have experience with working or training dogs before?*

YesNoOther
If yes, explain:
Would you be able to commit to prices, training, and communication during the training process?*

YesNoOther
If no, explain:
Have you ever been convicted of a misdemeanor, summary offense, or felony?*

YesNoOther
If yes, explain in detail including the state, date, and which conviction was made:
Please release the requested information regarding my condition to the above identified organization. This information will help determine my abilities regarding the placement of a Service Dog.

I understand that I can revoke this consent at any time by signing my name below:
Name of Applicant:*

First NameMiddle NameLast Name
Guardians name if user is under 18:

First NameMiddle NameLast Name
Date*

MonthDayYear
I have read, understand, and agree to this part of the application (initial):*
Guardian signature if applicant is under 18 (initial):

Part 3 - United Disabilities Services Foundation Entities:

United Disabilities Services Accessing independence/independent Living Services Adult Enrichment Nonprofit Management Solutions PRE- SERVICE DOG APPLICATION INQUIRY AUTHORIZATION RELEASE as a condition of receiving a Service Dog with United Disabilities Services Foundation (W.T.K.F) Service Dogs Program, I am aware that all applicants applying for a W.T.K Service Dog must submit to a background clearance, i.e a criminal record check and history. The clearance is for the protection of the program staff, trainers, consumers, and volunteers that are part of the W.T.K Service Dogs Program. I acknowledge that a telephonic facsimile or copy of this release shall be as valid as the original. This release is valid for all federal, state, county and local agencies and authorities. The following is my complete and legal name, and all information is true and correct to the best of my knowledge. I understand the penalty for falsifying any of the information listed below is grounds for immediate rejection of my application for W.T.K Service Dogs Program.

Applicants information, please print unless stated otherwise:
Name of applicant:*

First NameMiddle NameLast Name
Guardians name if user is under 18:

First NameMiddle NameLast Name
Birthdate:*

MonthDayYear
Race:*
Sex:*

MaleFemaleOther
Drivers License number:

.

State Issued in

CityState / Province

Postal / Zip Code
Continuous residence since:*

MonthDayYear
I have read, understand, and agree to this part of the application (initial):*
Guardian signature if applicant is under 18 (initial):
Virtual copy of Doctors note:

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(If applicable) Other accepted ways of sharing include a paper copy, email copy directly from provider. Ensure to hit "Submit" upon finishing application! Cancelof
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