Committed Canine T.E.A.C.H. enrollment application
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
E-mail
Age
Gender
Male
Female
Prefer not to answer
Other
Please review the dates for upcoming T.E.A.C.H. course dates at the website. Choose your first preference (your dog must be 10 months old to enroll.)
Please Select
Next Available SPRING
Next Available SUMMER
Next Available FALL
Not sure
Second chose for T.E.A.C.H. class date:
Next Available SPRING
Next Available SUMMER
Next Available FALL
Do you (the applicant) have a disability?
Yes
No
Is the applicant a minor child?
Yes
No
If a minor child, please provide a parent/guardian name:
Is the applicant a US military veteran?
Yes
No
Not military, but disabled Police officer
Not military, but disabled Fire Fighter
Will you will require an assistant dog handler in order to partner with a Service Dog? example: young child or significant physical disability
Yes
No
Maybe
If you answered Yes or Maybe to the above question, please provide name and relationship of the assistant.
What is your current living situation (select all that apply during a month's time)?
I live alone
I live with one other adult
I live with children
I live with more than one adult
Have you discussed your plans to train your dog to become a Service Dog with the adults in your home?
Yes
No
Other
Have you (the applicant) ever had a Service Dog?
Yes, I currently have a SD
Yes, in the past
No
Do you have the funds to enroll in the T.E.A.C.H. class?
Yes
No
Not sure
Are you able to travel to Brownstown, IL three times, for two days, separated by six weeks to attend the course?
Yes
No
Are you able to pay for your lodging and meals during the training classes?
Yes
No
Please describe your disability:
Please provide one or more tasks that you would like to train your dog to help mitigate your disability:
What or who helped you decide that choosing a Service Dog to help mitigate your disability seemed like a good choice for you?
T.E.A.C.H. is a Professionally Guided - Owner Trained program. Do you understand that you will be responsible to practice with your dog at home in-between the training classes?
Yes
No
Do you understand that you will be responsible to handle your dog in class, during public outings and its management and care during the training weekends?
Yes
No
How confident are you that you will be able to practice the lessons at home, between the training weekends?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Please rate your ability to impose your will on another person.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Please rate your agreement with this statement: "To resolve unacceptable behavior, a correction method should be used. To encourage a dog to present new /challenging behaviors, a positive reinforcement method should be used. A balanced approach to training makes sense to me."
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Have you reviewed the Committed Canine website regarding the T.E.A.C.H. program AND the requirements specified for your dog?
Yes
No
Does your dog meet the requirements listed at the Committed Canine website for enrollment in the T.E.A.C.H. program?
Yes
No
Don't Know
I didn't read the website
If you answered anything but YES in the above question, list any concerns you may have regarding your dog meeting the requirements for enrollment in T.E.A.C.H.
Do you understand that you need to pay $500 towards the enrollment to hold you spot in the class (it is non-refundable but transferable to a future class), and the remainder is due on the first day of the first class?)
Yes
No
Do you have a friend or family member who can attend the class with you to offer support?
Yes
Not Sure
No
Dog's Name
Dog's age
Dog's Breed
Dog's gender
Male Neutered
Male Intact
Female Spayed
Female Intact
Do you understand that your dog must be 10 months old (or older) to enroll in the class?
Yes
No
Select all that apply
My dog nips or bites other animals
My dog nips or bites people
My dog seems aggressive towards other animals
My dog seems aggressive towards people
My dog growls at other animals
My dog growls at people
I am a little afraid of my dog's behavior
I am quite afraid of my dog's behavior
I don't think I can handle my dog around distractions
My dog is fearful of new things or people
My dog seems overly shy in some situations
My dog seems highly protective of me or other family members
My dog has evidence of health issues such as hip dysplasia, progressive vision loss, routine ear or skin infections
My dog presents high prey drive towards other animals like cats or squirrels
If I brought my dogs into a room with other dogs, he would whine or bark incessantly
I think my dog might snap at someone who tried to pet him
If you checked any of the above boxes, your dog is not an appropriate candidate for the T.E.A.C.H. class
We recommend that you seek a more suitable dog before proceeding.
Select all that apply
My dog barks quite often
My dog gets fixated on distractions and I find it hard to get his attention
My dog pulls on the leash so strongly that he has pulled me over
My dog lunges at gates or doors or other dogs
My dog runs away
If you selected any of the above, or you can think of similar issues, you may find it challenging to train and maintain your dog's behavior as a high functioning Service Dog.
We suggest that you consider the option of securing a more even-keeled dog, and we would like to speak with you on the phone before admitting you to a T.E.A.C.H. class - to gain more clarification about your dog's behavior.
Provide any additional information about yourself or your dog that you would like to share:
Do you understand that you must attend all of the scheduled class dates in order to complete the course, and participate in the Public Access Test on the final weekend?
Yes
No
Do you understand that if you bring a dog to class that shows signs of aggression or other serious anti-social behaviors or poses a risk to people or other dogs you will not be able to continue in the class?
Yes
No
Your dog must be vaccinated against Rabies and Distemper/Parvo to participate in the T.E.A.C.H. class. We ask that you mail or forward a copy of the veterinary record via email prior to class. By hitting Submit, you acknowledge that you must provide veterinary records and that you confirm that your dog is free of external (fleas / ticks) prior to coming to the event.
I understand and agree
I do not agree
Submit
Thank you for submitting the enrollment form.
We will contact you shortly regarding the availability in the class session that you selected.
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