Service Dog Application

Service Dog Application
Thin Line Service Dogs(TLSD) serves first responders and veterans with a qualifying disability. We are unable to serve you if your needs are outside of our predefined range of clientele. TLSD does not descriminate on the basis of race, color, creed, national origin, sex, age, religion, marital status, sexual orientation, gender identity, or expression, veteran or first responder status, HIV/AIDS status, physical or mental disability.

Your packet contains all of the following materials:

Service Dog Application
- Completed application to include the medical information
- Physician Statement of Disability
- Consent/Non-Consent for Medical Treatment Form
- Photo/Video Release Form
- General Release of Liability
- Applicants that are first responders (fire, police, dispatch, sheriff, etc.) should provide disability papers or current ID badge
- DD214 Form that contains separation for veterans (please black out SS #) or a photocopy (front and back) of military ID card for active duty military
- A Photo of yourself
Photo/Video Release
About Thin Line Service Dogs

Thin Line is a 501(c)(3) nonprofit with a mission to provide trained service dogs to disabled first responders and veterans at no cost.
Dear Applicant:

Thank you for your interest in obtaining a service dog from Thin Line Service Dogs, Inc. Enclosed is an application packet that must be completed in its entirety before we will process your application. Incomplete application packets will not be considered.
Part I: Personal Information

This section covers you name, address, email, phone, etc.
Name*

First NameLast Name
Email Address*
Work Email Address
example@example.com
Phone Number*

Area CodePhone Number
Alternative Phone Number*

Area CodePhone Number
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever been convicted of a felony?*

YesNo
If "Yes", when and what was the outcome?
Are there currently any felony charges pending against you?*

YesNo
If "Yes", when and what was the outcome?
Have you ever been charged or attended a mandated class due to the charge of a DUI or DUID?*

YesNo
If "Yes", when and what was the outcome?
Part II: Family/Living Situation

This sections identifies your living status.
What is your marital status?*

Single, never marriedMarriedDivorced/seperatedWidowedOther
In what type of residence do you reside?*

Private home (I own)Private home (rental)ApartmentDormitoryAssisted LivingGroup HomeMobile HomeOther
Do you live in a single story home?*

YesNoIf, no is there an elevator available for your use?YesNo
Are there stairs that lead up to your residence?*

YesIf yes, is there a ramp for your use?No
Whom do you live with?*

AloneWith spouse/significant otherWith minor child(red)With live-in caregiverWith parentsWith grown childrenWith roommate(s)Other
Do you have any children (foster, adopted and step children, included)?*

YesNo
If "Yes" to the above, please specify gender and ages:
Are there any other family members in you home with disabilities?*

YesNoN/A
If "Yes" to the above, please soecify?
Do you have a yard?*

YesNo
If "Yes" to the above, is it fenced?

YesNo
If "Yes" to the above, what type?
Is there an in-ground pool in your yard?*

YesNo
If "Yes" to the above, is there fencing around it?
Part III: Demographic Information

We are gathering important demographic information to track progress of inclusivity and diversity measures being taken within our organization. To the extent you are comfortable, please select the options that best reflect how you identify.
Gender:

FemaleMalePrefer not to answer
Ethnicity:

CaucasianAfrican AmericanHispanicLatinoAsianOther
Part VI: Employment
What is your current employment status?*

Employed, full timeEmployed, part timeEmployed, SelfUnemployedRetired, tenureRetired, disabilityVolunteerAttend schoolOther
What is your primary source of income?*

Self, through employmentDisabilitySpouse or significant otherOther
Do you work outside of the home?*

YesNo
If "Yes" to the above, where do you work?
What is your job title?*
What are your hours of work?
Are you regularly exposed to paints, fumes, chemicals, or other potential toxins where you work?*

YesNo
Is you work location stationary (ex. office/desk job, classroom)?*

YesNoN/A
If no, please explain:
Part V: Pets

This section covers your current and past pets, as well as, knowledge of care and veterinarian.
Do you currently have any pets in your home?*

YesNo
If "Yes" to the above, please describe the number, type, gender, breed, intact and ages of all pets:
Have you ever had a dog before?*

YesNo
If "Yes" to the above, please tell us what breed, how long you had it and how you were able to care for the dog:
Is anyone in your home allergic to animals*

YesNo
If yes, please explain:
Does anyone in your home have a fear of dogs?*

YesNo
If yes, please explain:
Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?*

YesNo
If "Yes" to the above, please explain:
Please provide the name, address, and phone of your veterinarian:
If you qualify for a service dog, are you limited to a specific gender?*

YesNo
Part VI: Public Servant

Thank you for your service! This section covers where, how long and involvement in your community.
Are you a military veteran?*

YesNo
If "Yes" to the above, in which branch of the military did you serve?

ArmyNavyMarinesAir ForceCoast GuardNational Guard
Did you serve in combat?*

YesNo
If "Yes" to the above, please provide the dates of your tour(s) of duty :
Have you ever worked as a public servant in any of the following positions?*

Police OfficerFirefighterEmergency Medical ServicesSheriff's OfficeDispatchOther
What department do/did you work for?
Dates of employment:
What is/was your rank?
Date of retirement or disability:
Part V: Medical History

This section covers your medical information, including and not limited to date of diagnosis, treatment information, physician information and release to contact clinician.
Please describe the nature of your disability:*
Describe your current/previous occupation: *
Was your disability job related?*

YesNo
If "Yes" to the above, when were you first diagnosed?
Are you on any prescription medication?*

YesNo
If "Yes" to the above, please provide the prescription(s) medication you are currently taking, to include dosage and x's per day.:
Do you use any "recreational" drugs?*

YesNo
Is your disability considered to be progressive?*

YesNo
Do you have a secondary disability? *
If "Yes" to the above, please explain:
Name of Health Care Provider(s):*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Do you give TLSD permission to contact your current health care provider regarding your condition?*

YesNo
Have you discussed the aide of a service dog with your health care provider(s)?*

YesNo
What type of service dog are you requesting? (Please note that TLSD does not train hearing, guide, alert or autism dogs)*

MedicalMobilityPsychological (PTSD)
Do you currently use any of the following assistive/adaptive devices?*

Manual WheelchairCrutch/CanePower WheelchairLeg BraceArm BraceWalkerProsthesisHearing AidNone
Please indicate which of the following activities are limited by your disability:*

BalanceCoordinationMemory LossSpeechAbility to navigate curbs and stepsAbility to go out in public or socializeVisionHearingPhysical StaminaAbility to bend or retrieve dropped objectsAbility to live independentlyMuscular weaknessOther
If you answered "Yes" to the above question, please provide detail:
Do you currently experience any of the following?*

AllergiesSeizuresHeightened emotionsChronic painBalanceDepressionBrittle bonesSkin sensitivityHeat/Cold sensitivityNone
Is your voice:*

LoudAverageSoft

Can you:*

	Always	Often	Sometimes	Never
Pick up items off of the floor?
Push elevator buttons?
Turn lights on and off?
Push a manual wheelchair?
Flex your wrist?
Make a fist?

Do you:*

DriveTravel distances on foot/wheelsRide busesDriven by othersFly in airplanesTravel by trainOther
Do you have a valid driver's license?*

YesNo
Do you currently operate a motor vehicle?*

YesNo
If you answered "Yes" to the above question, do you utilize any adaptive equipment while driving?
What tasks/jobs are you interested in having a service dog perform for you? Why?*
Please describe your home life, social activities, hobbies, and lifestyle in general?*
Please describe how you will handle the following areas of dog care:
A. Feeding*
B. Grooming*
C. Toileting*
D. Vet Care*
E. Financial Costs*
F. If you are hospitalized*
G. Flea problems*
H. Family, friend involvement*
I. Access issues*
J. Dog behavior problems*
Part IV: Financials

This section is to establish the financial stability to provide the upkeep of the service dog.
It is estimated that it cost approximately $1,500 annually for basic care. Are you financially able to provide that?*

YesNo
TLSD recommends pet insurance on all our dogs. This would be an additional expense. Is this insurance you are interested in?*

YesNo
What is your annual income?*
What is your combined annual income, if applicable?*
What are your monthly expenses?*
Please provide the names, emails, and contact numbers for 3 personal references:*
- By clicking the submit button, I agree to Thin Line Service Dogs Inc. placement process, will undergo a homecheck, and interview at the discretion of Thin Line Service Dogs, Inc.
- By clicking the submit button, I understand Thin Line Service Dogs, Inc. will check my references including veterinary and personal.
- By clicking the submit button, I understand that if I am paired with a service dog that Thin Line Service Dogs, Inc., will have the right to reclaim the dog at any time and immediately due to my inability to care or treat the dog properly.
- By clicking the submit button, I understand there if for any reason I can not care for the dog, I will return to Thin Line Service Dogs, Inc., immediately.
- By clicking the submit button, I agree to indemnify and hold harmless Thin Line Service Dogs, Inc. against any losses, lawsuits, claims, injury, damages incurred by me or to any persons or property by my service dog, once placement has been completed.
- By clicking the submit button, I understand that if a service dog is placed with me, it is my responsiblity to travel to WV for two weeks of training and will be at my own expense.
- By clicking the submit button, I give Thin Line Service Dogs, Inc permission to contact my medical provider(s) to seek information soley on the premises of service dog placement and will keep my medical information confidential.
- By clicking the submit button, I verify all of the above information is true and accurate.
Signature of Applicant*
Should be Empty:

About Thin Line Service Dogs

Dear Applicant:

Part I: Personal Information

Part II: Family/Living Situation

Part III: Demographic Information

Part VI: Employment

Part V: Pets

Part VI: Public Servant

Part V: Medical History

Please describe how you will handle the following areas of dog care:

Part IV: Financials