SERVICE DOG APPLICATION
Applicant Information
Full Name of Applicant (this is the person in Need of a Service Dog)
*
First Name
Last Name
Phone Number
*
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).
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)
Partner Name, Age, Occupation (If Applicable)
Are you filling this form out on behalf of the applicant?
Please Select
Yes
No
Name of Representative (person filling out this form)
First Name
Last Name
Phone Number of Representative (if different from above)
Please enter a valid phone number.
Email of Representative (if different from above)
example@example.com
Home Details
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
What type of home do you live in?
*
House
Apartment
Condo
Duplex
Other
What type of living area do you live in?
*
Large city
Medium-small city/town
Suburb
Rural/Country
Other
Do you have a yard?
Yes
No
Other
Is your yard fully fenced? (This isn't a dealbreaker!)
Yes - 4ft
Yes - 6ft
Yes - 8ft
No
Invisible fence only
A fence build is planned for the future
Please list any others living in the home. (Names are optional)
Name
Age
Gender
1
2
3
4
5
6
Longer list of people in home, please
Others living in the home, continued
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 Select
Yes
No
Please list any that visit your home regularly that may also interact with the dog.
Age
Gender
1
2
3
4
5
6
7
8
9
10
Longer list for regular visitors, please
Very Regular Visitors, continued
Age
Gender
11
12
13
14
15
16
17
18
19
20
Getting to Know Your Needs
Which Service Dog Training Program(s) are you interested in? (Select all that apply)
Fully Trained Program Dog
Board & Train w/ my own dog
Owner Training Program w/ my own dog
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)
Yes
No
Other
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?
Yes
No
Other
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?
Yes
No
I have an appt to receive one
I plan to make an appt for one in the future
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.)
Browse Files
Drag and drop files here
Choose a file
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of
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.
Mobility (weight-bearing)
Mobility (non weight-bearing)
Medical Alert/Response
Psychiatric Support
Search and Rescue Trailing
Other
I don't know yet
What type of medical alert do you need?
Diabetic
Seizure
PTSD
Cardiac
Migraine
Other
Please tell us a little about yourself and your lifestyle.
Current Pet Information
Do you currently have any animals living in your home/on your property?
*
Please Select
Yes
No
Please list any animals currently in your home.
*
Name
Species (Dog/Cat etc.)
Breed
Sex
Age
Spayed/Neutered?
Up to date on vaccinations?
1
2
3
4
5
Longer pet list, please
Animals currently in home, continued
*
Name
Dog/Cat/Rabbit etc.
Breed
Sex
Age
Spayed/Neutered?
Up to date on vaccinations?
6
7
8
9
10
Current Veterinarian (if applicable)
Name of Veterinarian
Name of veterinary clinic
Contact Number
City, State
Have you ever had to rehome an animal? What were the circumstances?
*
Financial
The cost of a program service dog is typically $12K-30K, depending on the time needed to complete training. We will discuss your needs in detail and I will give you a closer estimate based on tasks needed.
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.)
I would like to travel to Ohio to pick the dog up.
I am interested in delivery to me. Please prepare a travel quote for my location.
References
Please provide references that we may contact. Include those who have interacted/cared for your dog or who have witnessed you interact/care for your dog.
Personal References (Please provide at least one)
Full Name
Relationship
Contact Number
How long have they known you?
1
2
Groomer Reference (If applicable)
Name of Groomer
Name of Salon
Contact Number
City, State
1
Submit
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