Service Dog Program Application

Service Dog Program Application

www.unleashedniagara.com / info@unleashedniagara.com
Applicant's Name:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address:
example@example.com
Parent / Guardian Name:

First NameLast Name
Veterinary Clinic Name / Number:
What type of Service Dog Support are you looking for?
Have you ever raised / trained a dog before?
Do you have a letter from your healthcare provider stating that the applicant requires a service dog?
Do you own a dog you would like to train for this work?
Where did you purchase the dog?
Rescue, breeder, shelter, etc.
What breed is your dog and how old are they?
What are your training goals for your dog?
What training have you completed with your dog?
Where did you receive this training?
Name of school / trainer
Has your dog ever growled at, snapped at, nipped or bitten a person? Please explain
Is your dog shy or uncomfortable in new environments or when meeting new people? Please explain.
Does your dog show signs of separation anxiety when left alone (for example: pacing, whining, barking, destructive behaviour, or distress when you leave)?
Does the dog have any health issues or physical limitations? Food allergies?
How many hours a week do you have to train your dog?
Does anyone in your family home have allergies to dogs?
Who will be the primary handler of the dog?
What do you estimate the yearly cost of owning and caring for a service dog (after training) will be?
(Includes food, veterinary care, grooming, equipment, and other supplies.)
What do you estimate the cost of training a service dog to be?
What is your availability?
Please help our coaches understand how your disability impacts your life and how having a service dog would make a difference to you.
Please list some specific tasks your dog could do to help you
Please review this information

To help our coaches understand how best to support you during your lessons, please let us know which of the following activities you may find challenging.

Dog training often involves:
- listening to and following verbal instructions
- participating in a 30-60 minute lesson
- watching demonstrations
- remembering steps or cues
- bending, crouching, or sitting to work with your dog
- walking with your dog
- pressing a clicker
- holding a leash
- putting equipment on and off your dog
- handing your dog treats
- going to different locations to practice
- picking up after your dog
Which statement best describes your situation?
Is there anything else you think our coaches should know?
Should be Empty: