Service Dog Application

Full Name of Applicant (this is the person in Need of a Service Dog)

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Applicant Age

We ask so we can fit the right dog temperament to you based on age and lifestyle.

If Applicant is a minor, please list parent/caretaker name(s).

Applicant Gender

We ask because some of our dogs may have a preference or nervousness toward men or women.

Applicant Occupation

Partner Name, Age, Occupation (If Applicable)

Are you filling this form out on behalf of the applicant?

Name of Representative (person filling out this form)

First NameLast Name

Phone Number of Representative (if different from above)

Please enter a valid phone number.Format: (000) 000-0000.

Email of Representative (if different from above)

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

What type of home do you live in?

What type of living area do you live in?

Do you have a yard?

Is your yard fully fenced? (This isn't a dealbreaker!)

Please list any others living in the home. (Names are optional)

Rows	Name	Age	Gender
1
2
3
4
5
6

Others living in the home, continued

Rows	Name	Age	Gender
7
8
9
10
11
12

Are there people that visit your home on a regular basis? (Caregivers, adult children, grandkids, friends, staff, etc)

Please list any that visit your home regularly that may also interact with the dog.

Rows	Age	Gender
1
2
3
4
5
6
7
8
9
10

Very Regular Visitors, continued

Rows	Age	Gender
11
12
13
14
15
16
17
18
19
20

Which Service Dog Training Program(s) are you interested in? (Select all that apply)

Is there a specific program dog currently in training you are hoping for? If so, please name them.

Are you open to a different dog if they are no longer available or if we feel someone else would be a better match for you?

Do you currently have your own dog that you want to be trained as a service dog? (If no, we can help find a good match)

We will perform a Service Dog Evaluation with you and determine if your dog has the right temperament for service work. If they do not, are you open to getting/receiving a different dog suitable for service?

Would you like our trainers' help in finding the right prospect for you?

Do you have an allergy to dogs?

Does anyone else living in the home have an allergy to dogs?

Do you have a doctors note prescribing a service dog to you?

Whenever convenient, please upload your doctor's letter of recommendation here if you currently have it. (This can be done later if you do not.)

Please let us know about the diagnoses or health conditions that cause you to need a service dog. (This will give us an initial idea of what type of dog you will need. We will discuss your needs in length later. )

If you know what type of service dog you need, please select all that apply from the list below. If you don't know yet, do not worry! We will talk in depth about your needs and we will figure it out together.

What type of medical alert do you need?

Please tell us a little about yourself and your lifestyle.

Do you currently have any animals living in your home/on your property?

Please list any animals currently in your home.

Rows	Name	Species (Dog/Cat etc.)	Breed	Sex	Age	Spayed/Neutered?	Up to date on vaccinations?
1
2
3
4
5

Animals currently in home, continued

Rows	Name	Dog/Cat/Rabbit etc.	Breed	Sex	Age	Spayed/Neutered?	Up to date on vaccinations?
6
7
8
9
10

Current Veterinarian (if applicable)

Rows	Name of Veterinarian	Name of veterinary clinic	Contact Number	City, State

Have you ever had to rehome an animal? What were the circumstances?

Do you agree with and are you able to pay for a service dog or the training required for your dog to become a service dog?

Would you like financing information?

Are you prepared to financially support your new dog for the rest of their life?

Would you prefer to travel for the handling class and pickup? Would you rather have us deliver the dog to you and have the handling class in your hometown for a travel fee? (Travel fee is dependant on how far you live from Xenia, OH and will be between $500 - $5,000. This would be calculated for you based on travel distance and local rates in your area.)

Personal References (Please provide at least one)

Rows	Full Name	Relationship	Contact Number	How long have they known you?
1
2

Groomer Reference (If applicable)

Rows	Name of Groomer	Name of Salon	Contact Number	City, State
1

SERVICE DOG APPLICATION

Applicant Information

Home Details

Getting to Know Your Needs

Current Pet Information

Financial

References