Facility Dog Application

Application - Facility Dog
ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org
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Will you be the owner/handler of the dog? (This means if you leave your current facility the dog will go with you to your next employment and retire with you).*

YesNo
If no, the facility will own the dog and we will require a second handler.

( This means the facility owns the dog and will be responsible for all veterinary care. If you leave your employment the dog would live with the 2nd handler)
Name of Second Handler.
Applicant
Date*

MonthDayYear
Date
Name*

First NameLast Name
Job Title*
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
Spouse Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Home Phone

Area CodePhone Number
Spouse Cell Phone

Area CodePhone Number
Spouse Work Phone

Area CodePhone Number
Spouse Email
example@example.com
Facility
Facility Name*
Facility Director or Principals Name*

First NameLast Name
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone*

Area CodePhone Number
Facility Director or Principals Email*
example@example.com
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Primary Phone*

Area CodePhone Number
Emergency Contact Secondary Phone

Area CodePhone Number

Facility Dog Information
Why do you want a Facility Dog? *
Please explain your understanding of animal assisted therapy and how you see it working for you?*
Describe the children or adults you are working with including any disabilities?*
What types of equipment are in use at your facility (wheel chairs, walkers, hearing aids, etc.)?*
Are there any other animals at your facility?*

yesno
If yes, please explain.

Personal Information
Are you financially able to feed and afford veterinary care for a dog?*

YesNo
Are you able to either bath and groom a dog yourself or pay for a groomer?*

YesNo
Do you require a specific breed of dog? If so please explain if this is a preference or a requirement and why. Keep in mind that we primarily train golden and labrador retrievers. We occasionally train standard poodles and other breeds. Requesting a specific breed will most likely result in a longer wait time.*
Does anyone in your household have allergies to dogs? If yes please explain.*
Have you added a puppy or kitten to your family in the last two years? If yes, please explain.*
Do you have any training difficulties, physical or emotional limitations, that may interfere with the ability to work as a team or care for a dog? If so, please give a detailed explanation*
Please list three people that will provide short term care for your dog, should you be unable to care for your dog, or should you be away on vacation.
Caretaker 1: Name*

First NameLast Name
Caretaker 1: Relationship to Applicant:*
Caretaker 1: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caretaker 1: Phone Number*

Area CodePhone Number
Caretaker 1: Email*
example@example.com
Caretaker 2: Name*

First NameLast Name
Caretaker 2: Relationship to Applicant:*
Caretaker 2: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Caretaker 2: Phone Number*

Area CodePhone Number
Caretaker 2: Email*
example@example.com
Caretaker 3: Name*

First NameLast Name
Caretaker 3: Relationship to Applicant:*
Caretaker 3: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caretaker 3: Phone Number*

Area CodePhone Number
Caretaker 3: Email*
example@example.com
Work
Do you work or volunteer at the position you wish to use your Facility Dog?*

Work Full TimeWork Part TimeVolunteer
Do you plan on using your Facility Dog at both your full or part time job and as a volunteer in another venue? If yes, please explain.*
Have you discussed the use of a Facility Dog with your employer and/or with your volunteer supervisor? If so please explain.*
Have you received permission from your work or volunteer job to use a Facility Dog? Please explain.*
If you plan on using your Facility dog in your full or part time job please fill out this section.
Approximately how many days and/or hours a week will your Facility Dog be at work with you?
If your Facility Dog is not at work with you, approximately how many days/hours will he/she be at home alone?
If you plan on using your Facility dog in a volunteer role please fill out this section.
Approximately how many days and/or hours a week will your Facility Dog be at your volunteer work?
If you have a regular paid job that your Facility Dog will not be going to, approximately how many hours will your dog be home alone?

Do you have any dog training experience? If so please explain.*
Are there specific skills or tasks that you would like your Facility Dog to learn?*
Will you be able to attend team training for a week in Center Conway, NH? Please elaborate if you have any restrictions. (NOTE: The cost of travel and the associated expenses including lodging and food are at your expense.) *

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

First NameLast Name
Vet Hospital/Practice Name*
Veterinarian Phone Number*

Area CodePhone Number
Veterinarian Email*
example@example.com

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, mothers, fathers, sisters, brothers, cousins 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.
First Reference
First Reference 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
Second Reference 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
Third Reference 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 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 may not be applied toward the fundraising minimum required.*

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 and 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, 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 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 to:

ACTS
2928 East Conway Road
Center Conway, NH 03813

Checklist of Items Needed Before Application Review:

- $100 Application Fee
- Completed Facility Dog Application
- 3 Personal References (must not be family members)
- Videos of home (interior and exterior) and workplace/school
- Video Conference Interview
- 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.
Name*

First NameLast Name
Please Sign and Submit*

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Application - Facility Dog