Reference Form

ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org

IMPORTANT INSTRUCTIONS: Please read carefully

Please use your TAB key to move on to the next entry box.

This form MUST be filled out in one session. If you leave the session, the form will NOT be saved.

Applicant

Today's Date*

Date

Applicant Name*

First NameLast Name

This Applicant is Applying to Train*

A Service DogA Facility Therapy dog

The above applicant has applied for our Owner Trained Dog Program. We thank you for taking the time to answer the following questions. We appreciate your thoughtful and honest response.

Your Information

Your Name*

First NameLast Name

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone *

Area CodePhone Number

Email*

example@example.com

Your Relationship to the Applicant*

How Long You Have Known the Applicant*

Service Dog Applicants ONLY

Please complete the below medical information if the applicant has a medical or psychiatric disability.

How does the applicants disability affect the applicants daily functioning? Please Explain.

Would any of the applicants medical conditions affect his/her ability to handle or care for a dog?

Does the applicant have any psychiatric disabilities that would affect his/her ability to complete or be successful in the training process?

Do you think the applicant would benefit from a service dog? Please explain.

Does the applicant have any dog training experience. Please explain

Are you aware of any misrepresentation from the applicant in relation to any of the following: The need for a service dog, the legitimate presence of a disability, the use or representation of any inappropriately trained or needed dog as a service dog, or the misrepresented use of an Emotional Support Dog in public places that do not normally allow dogs.

Facility Therapy Dog Applicants ONLY

Please complete the below medical information if the applicant has a medical or psychiatric disability.

Do you feel the applicant is a good candidate for a Facility Therapy Dog? Please Explain.

Has the applicant had any dog training experience to your knowledge? If yes please explain?

If you have knowledge of how the applicant wants to use his/her Facility Therapy Dog please explain.

Has the applicant done any Animal Assisted Therapy work or done any work with a Therapy Dog to your knowledge? Please Explain.

General Information

Tell us about the applicant. *

Does the applicant have any other dogs?*

yesno

If yes can you please tell us how the applicant cares for and interacts with his/her dog/s.*

If the applicant has dogs, are they well cared for and vetted when needed?*

If the applicant has dogs, are they trim and free from excess weight?*

If the applicant has dogs, do any of them live out side? If so, please explain.*

Does the applicant have any other animals? If so are they well cared for?*

Please explain in detail if you have any concern about the applicants use of a service dog or facility therapy dog.*

Additional comments

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*

When you click the SUBMIT button, the final version of this form will be sent to A.C.T.S.

Reference Form for Owner Trained Dog Applicants