Application - Service Dog

Application - Service Dog
ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org
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If applicant is under 18 years old. A parent or guardian must complete this application and sign on their behalf.
Applicant
Date*

MonthDayYear
Date
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical/Shipping Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Spouse
Spouse Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Emergency Contact
Emergency Contact Name*

First NameLast Name
Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Relationship to Applicant*
I give ACTS permission to obtain my medical information, confirming the type and degree of disabilty from my healthcare providers.

Yes
Physician
Physician Name*

First NameLast Name
Practice Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone *

Area CodePhone Number
Fax

Area CodePhone Number
Physical Therapist if Applicable
Physical Therapist Name

First NameLast Name
Phone

Area CodePhone Number
Occupational Therapist if Applicable
Occupational Therapist Name

First NameLast Name
Phone

Area CodePhone Number
Case Manager if Applicable
Case Manager Name

First NameLast Name
Phone

Area CodePhone Number
Medical Information
What is your primary diagnosis?*
What other medical issues do you have?*
How does this affect your daily living skills? What are your limitations?*
Are there restrictions or precautions as a result of your diagnosis?*

YesNo
Please Explain*
What type of medical treatments are you currently receiving?*
What medications are you taking and what are they for?*
What types of equipment do you use? (i.e. wheelchair, power chair, walker, etc.)*
Are you a smoker?*

YesNo
If you are a smoker, do you smoke in the house or car?
Are there any other smokers in the household?*

NoYes, One otherYes, Two otherYes, More than two others

Work
Do you work?*

Yes, full timeYes, part timeNo
If you work, do you want your dog to go to work with you?

YesNo
Have you discussed bringing your Service Dog to work with your employer? (A letter from your employer will be required.)

YesNo
Please supply us with any information regarding your work environment that may be helpful

Transportation
What type of transportation do you use? If you use public transportation please be specific.*
If you drive your own car, what type of car is it?

Veterinary Information
Please supply us with information on your current veterinarian or on the veterinarian you intend to use if you receive a service dog.
Veterinarian Name

First NameLast Name
Veterinary Practice/Hospital Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com

Training
Once all parts of your application are near completion, but prior to acceptance, we ask you to visit our training center in Center Conway, New Hampshire to meet our trainers and some of our dogs. Are you willing to do this?*

YesNo
Are you able to come to Center Conway, New Hampshire for two weeks of Team Training? You will be responsible for all travel expenses.*

YesNo
Are you able to bring someone to assist you during team training?*

YesNo
Please supply us with any other information regarding the team training process that you feel is relevant.

References
Please supply us with three references. Once we receive this form we will email the link to the Reference Form to each of your references. Please let them know that you have chosen them. Make them aware that they will be receiving a link from us via email.

You should choose your references carefully. Please do not select immediate family members like husbands, wives, children, brothers, sisters, cousins, mothers, or fathers etc. The best references are individuals who can speak without prejudice to your character in general, your capabilities, and your individual experiences with dogs if you have had dogs.

If you currently have, or have ever had, a service dog, we require one reference to be from your veterinarian.
First Reference
Reference 1 Name*

First NameLast Name
Relationship to Applicant:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Second Reference
Reference 2 Name*

First NameLast Name
Relationship to Applicant:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Third Reference
Reference 3 Name*

First NameLast Name
Relationship to Applicant:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com

Other
Is there any other information that you would like to add to your application?
Conditions
I understand that there is a $100 non-refundable processing fee to be mailed to ACTS, 2928 East Conway Road, Center Conway, NH 03813 and that this fee will not be applied toward the fundraising minimum.*

Yes
I understand that ACTS reserves the right to conduct a background check.*

Yes
I understand that no placements will be made in any household with either a younger (under the age of 2) dog or cat.*

Yes
I understand that ACTS reserves the right to conduct a home visit or to utilize video conferencing as part of the application process.*

Yes
I understand that my application will not be considered complete until all parts of the application have been submitted, including: Application Form, $100 Application Fee, Medical Form, Three References, "Home Visit" or "Video Conference" Interview and in person visit to our training center. I understand that the application committee will review my completed application - including all of the above - and determine if I will be a candidate and placed on the wait list. I understand that I will not be placed on the wait list until this process is complete.*

Yes
I understand that the wait time for a dog can be lengthy (2 years or more) and that during that time there can be changes in fees.*

Yes
I understand that during the time I am waiting for a dog there may be unforeseen changes in the organization or in the industry that may result in the inability of ACTS to provide me with a dog.*

Yes
I understand that if I do not complete all aspects in the application process in a timely manner or maintain communication with ACTS that I will need to begin the application process again.*

Yes
Please mail your application fee of $100.00 to:

ACTS
2928 East Conway Road
Center Conway, NH 03813

Checklist of Items Needed Before Application Review:

- $100 Application Fee
- Completed Service Dog Application
- Service Dog Medical Form (to be completed by your provider)
- 3 References (no immediate family)
- Videos of home (interior and exterior) and workplace/school
- Video Conference Interview or Home Visit
- In-person visit to our training center in Center Conway, NH, to meet our trainers and some of our dogs
I acknowledge that by submitting my name and signing below, that all the above information is accurate and that I fully understand all the conditions presented above.
Name*

First NameLast Name
If applicant is under 18 years old, parent or guardian must sign on their behalf

First NameLast Name
Please Sign and Submit*

Clear
When you click the SUBMIT button, the final version of your form will be sent to ACTS.
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