Canine Angels Dog Questionnaire

Canine Angels Dog Questionnaire
Canine Angels Service Teams

1630 Williams Hwy., PMB #260, Grants Pass, OR. 97527 888 K9 ANGLS or 541-846-6400 www.Canine-Angels.org email: info@Canine-Angels.org
Mother's Name

First NameLast Name
Father's Name

First NameLast Name
Child's Name

First NameLast Name
Child's Age
Child's Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Please describe your child's disability(ies)
Is the disability progressive?
Does the applicant use:

Other
Is the applicant's mental development at an average level?
Comprehension and ability to follow directions ok?
Working at what age level?
How is the applicant's speech?
Do parents live together?
Mother's occupation
Please specify
Father's occupation
Please specify
Activity level (away from home)
What's a typical day life for the applicant and family?
Please list names and relationship of all people living in your home and ages of minors:
Has the applicant been exposed to dogs?
Was the interaction positive?
Any fear of certain kinds of dogs?
If yes, please explain.
Has the applicant family ever had a dog before?
Is anyone in the household allergic to dogs?
Please tell us about any pets in the home (breed, age, gender)?
Whose idea was it to get an assistance dog?
How do you think your child will benefit from having an assistance dog?
What specific tasks would applicant/family like their dog to perform?
Do all family members agree on the decision to apply for an assistance dog?
If no, please explain.
Has the family considered the extra costs of having a dog, including quality food, dog supplies, and preventative care such as shots, heartworm and flea medication, and teeth cleaning?
Has the family considered the extra time for training, grooming, and exercise, plus poop patrol? The dog must be picked up after 100% of the time…no exceptions.
Is the family aware of the $50 application processing fee and that there will be a Team Training class fee (Team Training Class fee varies depending on the level of training class for the applicant and their new assistance dog partner)? Canine Angels can offer advice and assistance for fundraising.
Is the family aware that Team Training is located in Grants Pass, Oregon, and that travel, lodging, field trips, and some meals are the responsibility of the applicant family?
Is there anything else that Canine Angels should know?
How did you find out about us?
Should be Empty:

Canine Angels Dog Questionnaire

Canine Angels Service Teams