Vested Partners, 8595 Pelham Road, Greenville, SC 29615.
Service Dog Application for an ADULT
ALL ANSWERS ARE REQUIRED. INCOMPLETE APPLICATIONS CANNOT 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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Service Dog's Job
Please give your disability diagnosis and date acquired:
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Primary type of work dog would perform:
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Please Select
Mobility Assistance
Medical Alert
Psychiatric Assistance
Please list the five primary tasks the dog would be required to perform. Give details.
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Do you use any of the following? Check ALL that apply.
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Electric Wheelchair
Manual Wheelchair
Crutches or cane
Vehicle with moving ramp
Adapted Driving
Augumentative Alternative Communication
Sign Language
None of the above.
Please describe your approximate physical size, height, and functionality, including whether or not you could care for, feed, groom, and transport the dog wiithout assistance.
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Do you wish for this dog to be certified for Public Access?
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Please Select
Yes
No
Undecided
About Your Family
How many adults in your household?
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How many children in your household?
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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.
About Your Home
Type of residence
*
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:
*
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?
*
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
*
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
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.
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
Planning for a Service Dog
The following information would give us preliminary info on how well--or how soon--we might be able to match you with a dog. Please think carefully about each answer.
I plan to do the following activities with my dog: (check all that apply)
Assist me in Public Places
Accompany me to work or volunteer position
Travel
Accompany me to medical or related appointments
Ride Public Transportation
Accompany me on an electric scooter or wheelchair
Accompany me to classes
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
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
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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What else would you like to tell us about your home, your family, your current pets, the particular needs related to assisting with your disability, and/or your desire for a service dog from VP?
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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 VP 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 18 years of age.
*
Acknowledged and agreed.
I understand that all training--initial, followup, and problem management--takes place at in Greenville, SC and I am responsible for my own travel arrangements to and from the facility.
*
Acknowledged and agreed.
PLEASE NOTE and ACKNOWLEDGE: I understand that this is an APPLICATION ONLY and that Vested Partners 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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