Committed Canine Service Dog CUSTOM TRAINING

Committed Canine Service Dog CUSTOM TRAINING
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
2nd Phone Number

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

YesNo
If a child, please add parent/guardian's name:
Is applicant a US military veteran, or disabled Police or Firefighter?

NoYes
Date of Birth

MonthDayYear
Gender

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

NoYes
Do you currently use a Service Dog?

NoYes
Have you ever used a Service Dog?

NoYes
Have you reviewed the Committed Canine website?

YesNoSome of it
Do you currently have the funds to pay for the training of a Custom Trained dog?

NoYesNo, but I will have themNo, 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?

NoYes
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?

YesNo
Do you understand and agree that owning a Service Dog will require daily practice for the life of the dog's service career?

YesNo
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)

YesNo
Dog you have the funds to purchase flea/tick preventative (approx. $4 - $11/month)

YesNo
Do you have the funds to purchase heartworm preventative (approx. $5 - $12/month)

YesNo
Do you have the funds to purchase annual veterinary care for your dog (approx. $50 - $250 / yr)

YesNo
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?

NoYesI'm not sureI 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/walkingMobility wheelchair assistAutismAlert (seizure, medical event)Other describe below
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 animalsMy dog nips or bites peopleMy dog seems aggressive towards other animalsMy dog seems aggressive towards peopleMy dog sometimes growls at other animalsMy dog sometimes growls at peopleI am a little afraid of my dog's behaviorI am quite afraid of my dog's behaviorMy dog seems overly shy in some situationsMy dog seems highly protective of me or other family membersMy 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 incessantlyI think my dog might snap at someone who tried to pet himMy dog has tried to snap at me when I touched it in a specific place, or when I brush it or cut its nailsI would like to apply for a Committed Canine Service Dog in TrainingOther
If you selected "other" add details here
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?

YesNoNot 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 childYes, and I currently own a dogYes, as an adult but I don't currently own a dogNo, I have never owned a dog before
Have you trained a dog before?

NeverA pet over five years agoA pet in the past five yearsA 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?

YesNo, but I plan to do thatI do not live with anyone, but I spoke with friends or familyI 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 yardLet out in un-secured yard (supervised)Let out in un-secured yard (unsupervised)Walk on leashLet 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?

YesNo
Do you currently have the dog you want to have trained?

YesNoNo, but it has been identified
If you have a dog, what is his name?
If you have a dog, what is his gender?

Male - neuteredMale - intactFemale - spayedFemale - 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?

YesNo
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?

YesNo
Does the dog you plan to have trained meet the criteria at the website?

YesNoNot 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 20% 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 40% (final payment) is due on the first day of the Handler Instruction when you come for your dog?

YesNo
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?

YesNo
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