Canine Angels Dog Questionnaire
Canine Angels Service Teams
13475 N. Applegate Rd.Grants Pass, OR. 97527 888 K9 ANGLS or 541 846-6400 www.Canine-Angels.org email: info@Canine-Angels.org
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Age
Child's Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Please describe your child's disability(ies)
Is the disability progressive?
Yes
No
Does the applicant use:
Manual wheelchair
Electric wheelchair
Braces
Crutches
Other
Is the applicant's mental development at an average level?
Yes
No
Comprehension and ability to follow directions ok?
Yes
No
Working at what age level?
How is the applicant's speech?
Good
Fair but understandable
Poor, difficult to understand
Stutter
Do parents live together?
Yes
No
Mother's occupation
Full time
Part time
Work from home
Please specify
Father's occupation
Full time
Part time
Work from home
Please specify
Activity level (away from home)
Most of the time
Some of the time
Hardly ever (except school)
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?
Yes
No
Was the interaction positive?
Yes
No
Any fear of certain kinds of dogs?
Yes
No
If yes, please explain.
Has the applicant family ever had a dog before?
Yes
No
Is anyone in the household allergic to dogs?
Yes
No
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?
Yes
No
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?
Yes
No
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.
Yes
No
Is the family aware of the $50 application processing fee and Team Training class fee ($2,500 for Pal and Facility Dogs, $3,500 for Service Dogs)? (dog is provided free of charge and Canine Angels can offer advice and assistance for fundraising)
Yes
No
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?
Yes
No
Is there anything else that Canine Angels should know?
How did you find out about us?
Submit
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