Aretas Assistance Dog Application
Email
*
example@example.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
If Applicant is Under 18, Parents' Names
Marital Status
*
Married
Single
Divorce
Widowed
Place of Employment
*
Type of Employment
*
Full Time
Part Time
None
What is your primary disability?
*
What caused your disability?
*
How long have you had the disability?
*
Has your disability been diagnosed by a physician?
*
Yes
No
Is your disability progressive?
*
Yes
No
Do you have any secondary disabilities?
*
Yes
No
If Yes, what are they?
What is your approximate height and weight?
*
If you go to school. where? Full or part time?
*
Emergency contact info (name and phone number)
*
Who lives in your house? (Name, Relationship, Age)
*
Where do you live?
*
House
Townhouse
Apartment
Dorm
Other
What kind of neighborhood?
*
Urban
Suburban
Rural
Do you own or rent?
*
Own
Rent
Do you have a fenced yard?
*
Yes
No
Do you have any allergies? If do, describe them
*
Does anyone in your house have allergies or a fear of dogs?
*
Yes
No
What mobility aids do you use?
*
Cane
Wrist brace
Walker
Leg brace
Manual wheelchair
Electric Wheelchair
Prostheses
Hearing aid
Other
Please list your primary care physician, physical therapist, psychologist, occupational therapists and any other health care professionals that are part of your team, along with phone numbers
*
Do you have an attendant?
*
Yes
No
Do you have a criminal history, pending charges, parole, probation or DUI charges?
*
Yes
No
Do any children visit your home? If yes, please explain
*
Please list any current pets you have
*
Please list any other animals that visit your house
*
Do you understand that the use of a service dog will identify you as a person with a disability?
*
Yes
No
Have you ever had a dog? Tell us about it
*
Are you able to care for a dog yourself? If not, who will help care for the dog?
*
Does anyone in the house have concerns about you getting a service dog?
*
Yes
No
Do you plan to move in the next two years?
*
Yes
No
Will your dog accompany you to work?
*
Yes
No
Will your dog accompany you to school?
*
Yes
No
How many hours a week are you away from home?
*
Where are the primary places you go?
*
Work
School
Shopping
Restaurants
Church
Groups
Visiting People
Exercise
Errands
Medical visits
Does someone accompany you when you go out in public?
*
Yes
No
What kind of travel do you do?
*
Do you take airplane trips?
*
Yes
No
Can you afford food, veterinary care and supplies for your service dog?
*
Yes
No
What other service dog organizations have you applied to?
*
Are you looking for a fully-training service dog, or owner-training a service dog with professional assistance?
*
Fully-trained
Owner-training
If you selected the fully-trained service dog option above, are you (and a caregiver if applicable) able to attend a two-week training camp at Aretas Assistance Dogs?
*
Yes
No
How would you work around your work or school schedule to do so?
*
How do you feel a service dog could improve your life? What tasks do you think a dog might be able to do for you?
*
What are your hobbies, activities and interests? Tell us a little about yourself.
*
How would you describe yourself?
*
Introvert
Extrovert
Somewhere in between
Pick the five words that describe the kind of dog that most appeals to you
*
Serious
Willing
Smart
Happy
Devoted
Trusting
Slow
Attentive
Sweet
Excitable
Playful
Sassy
Energetic
Dependable
Easy-going
Friendly
Communicative
Sensible
Stable,
Independent
Affectionate
Calm
Busy
Responsible
Confident
Assertive
Funny
Protective
Silly
Pick five words that describe the kind of dog that does not appeal to you?
*
Serious
Slow
Sassy
Excitable
Playful
Energetic
Easy-going
Independent
Affectionate
Calm
Busy
Assertive
Funny
Protective
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