My Service Dogs Place

Service Animal Handlers Full Name*

Phone Number with area code*

Phone Number is*

CellHomeOther

E-mail*

I am a*

Service Dog's Name*

Dog Age*

Dog Breed*

Dog Weight*

Veterinarian's Name for the Service Dog?*

Phone of Veterinarian?*

Give a brief description of your Service Dog *

To your knowledge is your Service Dog up to date on all of their other shots?*

YesNoI am Unsure

To your knowledge is your Service Dog free of fleas, ticks or disease that would endanger people or other animals?*

YesNoI am Unsure

Is your Service Dog?*

NeuteredNot NeuteredSpayedNot Spayed

Does your service dog have any medical issues we need to be aware of?*

Is your Service Dog vaccinated for rabies?*

Date last vaccinated:*

My service dog has been trained to do work or perform tasks to assist me with my disability and has been trained to behave in a public setting.*

YesNoI am Unsure

What service has your service dog been trained to provide?*

I need my service dog to be cared for because I will be admitted to/attending program at:*

James A HaleyBay PinesOther

What are the dates you need to have your Service Dog taken care of?

Start Date*

Date

End Date*

Date

Provide your Case Worker's or a Contact Person's name and their phone number below who has permission to speak with My Service Dog's Place on your behalf concerning your service dog and the date that you will be or have been released from medical care.

Name of my Case Worker/Contact Person?*

Phone Number?*

Give name of Animal Trainer OR the Training Organization of your Service Dog: *

Phone number of Animal Trainer OR Training Organization OR Registry ID#:*

To the best of my knowledge, my service dog has not behaved aggressively or cause serious injury to another person or dog.*

YesNoI am Unsure

If you answered NO to the above question, please explain the aggressiveness?

By my signature below I acknowledge that I have read, understand and agree to the following statements:

I understand and agree that a properly trained service dog does not act aggressively by biting, barking at, jumping on, lunging at, or injuring people or other animals. It also does not urinate or defecate inside buildings or houses.

I understand and agree that My Service Dog's Place has my permission to contact and utilize any veterinarian and their veterinary care/medical services that they deem necessary for the safety and wellbeing of my service dog.

I understand and agree that My Service Dog's Place is taking care of/pet setting my service dog at no cost to me while I get the medical attention I need. Due to this, it is my responsiblity to pick up my service dog or make arrangements to have my service dog picked up for me within 48 hours of the end date provided above unless I, or my Case Worker/Contact Person has, on my behalf, requested to extend the end date due to my medical care being extended. Additionally, I understand and agree that if I need to have the end date extended, it must be requested by phone by calling MSDP at 813-997-4050 or 813-321-0880 ext # 5 AND by filling out request for extension date form located on our My Service Dog's Place program page on our website at: www.mywarriorsplace.org/msdp

I understand and agree that if I fail to pick up my service dog or have my service dog picked up on my behalf within 48 hours of the end date provided above or by the end date that has been extended on my behalf (by phone call and by submitting an end date extention form), that it will be considered an owner surrender of my service dog and that My Service Dog's Place has my permission to rehome my service dog.

*Note: If handler is unable to fill out this form then the Case Worker/Contact Person listed on this form will sign on behalf of the handler. Additionally they will make sure that the handler is given a copy of this form.

Signature*

Date of Signature and Submission*

DateHourMinutesAM/PM Option

FOR YOUR RECORDS: MAKE SURE TO PRINT FORM BEFORE YOU SUBMIT IT

My Service Dogs Place Intake Form