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.
Your Email Address:
example@example.com
Parent / Guardian Name:

First NameLast Name
Veterinary Clinic Name / Number:
At home supportFacility SupportPublic Access SupportI would like to discuss what might be the best fit
YesNo
YesNo
YesNo
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.
YesNo
Does the dog have any health issues or physical limitations? Food allergies?
How many hours a week do you have to train your dog?
YesNo
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.)
Less than $5,000$5,000 - $10,000$10,000 - $20,000More than $20,000Not sure
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
I can comfortably participate in all of these activities without accommodation.I can participate in most of these activities, I may need some minor adjustments.I may need accommodations or alternative approaches for several of these activities.I’m not sure — I’d like to discuss this with a coach
Is there anything else you think our coaches should know?
Should be Empty: