Committed Canine Service Dog CUSTOM TRAINING

Committed Canine Service Dog CUSTOM TRAINING
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
2nd Phone Number

Area Code Phone Number
E-mail (please verify your entry for accuracy)
Is the applicant a minor child?

Yes No
If a child, please add parent/guardian's name:
Is applicant a US military veteran, or disabled Police or Firefighter?

No Yes
Date of Birth

Month Day Year
Gender

Male Female other
Height (if using dog for mobility)
Weight (if using dog for moblity)
Do you have a disability?

No Yes
Do you currently use a Service Dog?

No Yes
Have you ever used a Service Dog?

No Yes
Have you reviewed the Committed Canine website?

Yes No Some of it
Do you currently have the funds to pay for the training of a Custom Trained dog?

No Yes No, but I will have them No, I will not have the funds for Service Dog training
Are you able to travel to Brownstown, IL to receive training on how to handle your Service Dog?

No Yes
Do you understand that you will be required to come for Handler Instruction over three days at the conclusion of your dog's training, AND again 4 weeks later for two days?

Yes No
Do you understand and agree that owning a Service Dog will require daily practice for the life of the dog's service career?

Yes No
Describe concerns you may have regarding continued training of your Service Dog:
Do you have the funds to purchase food for your dog (approximately $10-$40/month)

Yes No
Dog you have the funds to purchase flea/tick preventative (approx. $4 - $11/month)

Yes No
Do you have the funds to purchase heartworm preventative (approx. $5 - $12/month)

Yes No
Do you have the funds to purchase annual veterinary care for your dog (approx. $50 - $250 / yr)

Yes No
Do you have the wherewithal (capacity) to maintain a dog on a daily basis, including two to four exercise periods, regularly scheduled feeding, grooming, routine training?

No Yes I'm not sure I cannot do that, but I have help and the dog will receive proper care
If you selected "not sure" or "I have help" in the answer above, please describe your situation further including how the dog's daily care will be addressed.
Select all areas where you hope a Service Dog will help to mitigate your disabilite:

A psychiatric disability (PTSD, panic/anxiety, bipolar, clinical depression etc...) Mobility balance/walking Mobility wheelchair assist Autism Alert (seizure, medical event) Other describe below
If you selected "other" add details here
Select all that apply to the dog you have selected to have trained as your Service Dog:

I don't have the dog, yet (if so, move to the next question) 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 sometimes growls at other animals My dog sometimes growls at people I am a little afraid of my dog's behavior I am quite afraid of my dog's behavior 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, vision or hearing loss, routine ear or skin infections, etc... If I brought my dog 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 My dog has tried to snap at me when I touched it in a specific place, or when I brush it or cut its nails
If you selected any of the above, your dog is not appropriate for Service Dog training. We recommend that you consider identifying another dog.
Are you able to bring a support person with you to the Handler Instruction?

Yes No Not sure
Describe your disability
Describe one or more tasks which you believe a dog can perform to help mitigate your disability

Describe your level of self confidence when you must learn something new

	1	2	3	4	5

1 is Worst, 5 is Best

Describe your level of self-confidence once you understand a task and have had some practice

	1	2	3	4	5

1 is Worst, 5 is Best

How would you rate your ability to impose your will upon someone:

	1	2	3	4	5

1 is Worst, 5 is Best

Have you owned a dog before?

Yes, but only when I was a child Yes, and I currently own a dog Yes, as an adult but I don't currently own a dog No, I have never owned a dog before
Have you trained a dog before?

Never A pet over five years ago A pet in the past five years A Service Dog that I still use
Have you discussed the idea of acquiring a Service Dog with any family or friends with whom you share a home?

Yes No, but I plan to do that I do not live with anyone, but I spoke with friends or family I don't live with anyone, and I have not spoken with anyone about it
How will you manage your Service Dog for expercise / potty breaks?

Let out in fenced yard Let out in un-secured yard (supervised) Let out in un-secured yard (unsupervised) Walk on leash Let out in enclosed kennel
Please list any other pets that you have in your home (species, breed, gender, age, etc...)
Do you understand that you will have to source your dog for Custom Service Dog training with Committed Canine?

Yes No
Do you currently have the dog you want to have trained?

Yes No No, but it has been identified
If you have a dog, what is his name?
If you have a dog, what is his gender?

Male - neutered Male - intact Female - spayed Female - intact
If you have a dog, how old is s/he?
Do you understand that the dog must be at least 10 months old to come for training?

Yes No
What breed do you have, or will acquire, or hope to acquire for your Service Dog?
Describe why you selected the breed, or plan to acquire the breed you are seeking. If you are not certain about what breed to acquire, lists breeds that interest you, and why?
Have you read the information at the Committed Canine website regarding the requirements for the dog?

Yes No
Does the dog you plan to have trained meet the criteria at the website?

Yes No Not sure
Please review the Committed Canine schedule for Custom Training. When is the earliest session you would like to bring your dog?
Do you understand that a 10% non-refundable/but transferable deposit is required to hold your training spot. 40% of the fee is due when you bring your dog for training and 50% (final payment) is due on the first day of the Handler Instruction when you come for your dog?

Yes No
Do you understand that your dog must be vaccinated against rabies, distemper/parvo and bordetella before coming for training and that you must provide evidence of the vaccinations?

Yes No
Please provide any other information you would like us to know about your desire to schedule Custom Service Dog training at Committed Canine.
Please hit Submit below

We will contact you shortly about scheduling your dog's custom Service Dog training.
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Committed Canine Service Dog CUSTOM TRAINING

If you selected any of the above, your dog is not appropriate for Service Dog training. We recommend that you consider identifying another dog.

Please hit Submit below