Owner Trained Facility Dog Application

Owner Trained Facility Dog Application
ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org
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Applicant
Date*

MonthDayYear
Date
Name*

First NameLast Name
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
Name

First NameLast Name
Cell Phone

Area CodePhone Number
Work Phone

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

First NameLast Name
Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number

Facility Therapy Dog Information
Why do you want a Facility Therapy 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
Does anyone in your household have allergies to dogs? 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*

Work
Do you work or volunteer at the position you wish to use your Facility Therapy Dog?*

Work Full TimeWork Part TimeVolunteer
Do you plan on using your Facility Therapy 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 Therapy 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 Therapy Dog? Please explain.*
If you plan on using your Facility Therapy 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 Therapy Dog be at work with you?
If your Facility Therapy 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 Therapy dog in a volunteer role please fill out this section.
Approximately how many days and/or hours a week will your Facility Therapy Dog be at your volunteer work?
If you have a regular paid job that your Facility Therapy Dog will not be going to, approximately how many hours will your dog be home alone?

Training
Do you have any dog training experience? If so please explain.*
Are there specific skills or tasks that you would like your Facility Therapy Dog to learn?*
Will you be able to attend the required classes and 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 for team training, 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.
Name

First NameLast Name
Hospital Name*
Phone Number*

Area CodePhone Number
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, or fathers. 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
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Second Reference
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Third Reference
Name*

First NameLast Name
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 that 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 fee for a dog should I receive one.*

Yes
I understand that ACTS reserves the right to conduct a background check.*

Yes
I understand that ACTS reserves the right to conduct a home visit or 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, three references, and the $100 processing fee. I understand that once my application is complete, a "Home Visit" or a "Face Time" interview will be conducted as well as an evaluation of my dog. I understand that the application committee will review my completed application, references, home visit/face time call. and determine if I am eligible for the program. I understand that I will not be admitted into the program until this process is complete.*

Yes
I understand that there may be unforeseen changes in the organization or in the industry that may result in the inability of ACTS to provide me the agreed upon services, and that should this occur ACTS will prorate fees for a refund.*

Yes
I acknowledge that by submitting my name and signing below, that all the above information is accurate and that I fully understand all the conditions presented above.
Name*

First NameLast Name
Please Sign and Submit*

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