Weeping Tree Kennels Service Dog Application

Serve & Support K9 Academy Owner Service Dog Application

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

Thank you for requesting a Service Dog application from Serve & Support K9 Academy. 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 Serve & Support K9 Academy 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. Serve & Support K9 Academy respects the privacy of its applicants and recipients and all information is kept confidential between the Board of Directors.

Serve & Support K9 Academy 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 Serve & Support K9 Academy policy to treat everyone who comes in contact with our organization with respect and dignity at all times.
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:

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
Part 3: Dog Application
Dogs Name
Dogs Breed(s)
Dogs DOB (Est age)
Does said dog have any previous training?
Any known behavioral or physical issues with said dog?
Insert dogs current Vaccine records. You may also bring a physical copy during dogs evaluation.

Browse Files

Cancelof

Part 4 - 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 Service Dogs Program, I am aware that all applicants applying for a 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 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 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
Virtual copy of Doctors note:

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

MonthDayYear
Date
I have read, understand, and agree to this part of the application (initial):*

Powered by Jotform SignClear
Should be Empty:

Serve & Support K9 Academy Owner Service Dog Application