Vested Partners - Greenville, SC
Service Dog Application for a CHILD
ALL ANSWERS ARE REQUIRED. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
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Daytime Phone
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Area Code
Phone Number
E-mail
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About Your Family
How many adults in your household?
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How many children in your household?
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Name of the child for whom the dog will perform tasks?
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Who will be the primary caregiver for the dog?
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Who will be financially responsible for the dog?
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Does anyone in the home have asthma or allergies to dogs?
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Are all adults in the home in agreement about the need for a service dog?
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Please consider what time you leave for work or school and when you return home.
Please tell us the three most important tasks, in priority order, that the service dog needs to perform.
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Is the dog expected to respond to the direction and commands of the child? Or only to the parent?
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Please describe the age, physical size, and functionality of the child the dog is to assist. (ie: verbal? physically able to walk? physically able to handle and groom a dog? able to perceive and comprehend canine needs for food and water?)
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Please describe the average day's schedule in your household. Do all adults work? And if so, what hours and how do the schedules overlap? . We are specifically interested in how long a service dog would be left alone and where/how that would be handled.
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About Your Home
Type of residence
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Please Select
House
Mobile Home
Condo
Boarding House
Apartment
Dormitory
Other
Choose from drop-down
Do you:
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Please Select
Own
Rent
Live with parents
Other
Choose from drop-down
If you are a renter or live in a condo, please give contact information of Landlord or HOA:
Fenced Yard:
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Please Select
Privacy (6' or higher)
Chainlink (4')
Chainlink (5' or higher)
Other
None
Choose from drop-down
How long have you lived at this address?
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What issues do you anticipate needing to solve as a result of a dog moving into your home--a dog that will shed, have occasional illnesses, and need daily grooming care?
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About Your Current Animals
Species/Breed
Animal Age
Gender - Spayed/Neutered?
Species/Breed
Animal Age
Gender - Spayed/Neutered?
Species/Breed
Animal Age
Gender - Spayed/Neutered?
Species/Breed
Animal Age
Gender - Spayed/Neutered?
Current Veterinarian
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Name, Address, Phone to be used as a reference/contact.
What temperament or personality issues would affect your current animals adapting to a service dog?
Have you ever given a pet away, given it to a shelter or rescue group, returned it to a breeder, or sold it? If so please explain:
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Have you ever had an animal lost or stolen? If yes, please describe event and outcome:
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Have you ever had a dog die as a result of being hit by a car?
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Please Select
Yes
No
Choose from drop-down
What else would you like to tell us about your home, your family, your current pets, and/or your need to adopt a released dog from VP?
References
By providing the names below I grant permission to contact each person by phone for their viewpoint on the suitability of my home for a dog released from the VP program. If applying for SERVICE DOG, please include professional (i.e. therapist or doctor).
REFERENCE #1
First Name
Last Name
Relationship
Reference Phone #
-
Area Code
Phone Number
REFERENCE #2
First Name
Last Name
Relationship
Reference Phone #
-
Area Code
Phone Number
Relationship
Reference Phone #
-
Area Code
Phone Number
What veterinary practice do you plan to use?
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Energy level preferred in the service dog?
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Please Select
Low (couch potato)
Medium (average family pet)
High (active family pet)
Turbo (working dog who requires a JOB)
Choose from drop-down
I plan to do the following activities with my dog: (check all that apply)
Walks on leash
Take to work
Go to dog park
Hike or jog
Hunt
Play frisbee
Retrieve balls
Swim
Travel
Sleep
When it comes to controlling dogs, I consider myself:
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Please Select
A strong leader (dog must sit for a cookie and follow my rules)
Lenient (a little permissive, can be coaxed to give a dog a treat or petting on demand)
Not sure why it matters
Choose from drop-down
I understand and agree that no service dog is ever to be tied up unattended at any time.
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By checking this box I acknowledge the requirement that no dog adopted from DFA may be tied up unattended under any circumstances.
Important Details!
Please acknowledge each condition by checking the box to the right.
I hereby acknowledge that I am at least 21 years of age.
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Acknowledged and agreed.
I understand that all training--initial, followup, and problem management--takes place at the DFA facility in SC and I am responsible for my own travel arrangements to and from the facility.
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Acknowledged and agreed.
I understand that this is an APPLICATION ONLY and that Dogs for Autism retains sole discretion in the training and placement of any dogs and reserves the right to modify or expand this application at any time or to deny any application. The time frame is open ended and depends entirely upon availability of dogs and the volume of charitable contributions.
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Acknowledged and agreed.
Enter the message as it's shown
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Typing my name in the box to the right constitutes my electronic signature, my verification of the truth of all above statements, and my agreement to all terms specified in this application.
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