Your Name and Address Salutation* : ---Dr.Mr.Mrs.Ms. Under 21 or incapable of competently caring for a dog?* YesNo If no, please add custodial parent or guardian contact info. Custodial Information Salutation : ---Dr.Mr.Mrs.Ms. I approve all communications going to both me and my guardian. Additional Contact Information Would you like to add an additional contact? YesNo If yes, please add below. Salutation: ---Dr.Mr.Mrs.Ms. About You Do you require a Hearing Alert Dog?* YesNo Do you require a Seizure Alert Dog?* YesNo Do you require a Hypoallergenic Dog?* YesNo Are your living arrangements conducive to caring for a Service Dog?* YesNo Explanation: Do you have a support system (family and/or friends) to assist with transitioning to life with our Service Dog and with the responsibilities of owning a dog?* YesNo Explanation: A Service Dog will cost $1,500+/year to feed and provide vet care. Can you afford this?* YesNo Explanation: Will the applicant (and Parent/Guardian/Caretaker if relevant) be able to attend a 12 day training session in Putnam County, NY? You will be responsible for room and board during this period with some assistance from us.* YesNo Explanation: Your Personal Information Your Birth date : Your Height : " ' (Feet/Inches) Your Weight : Marital Status : SingleMarriedWidowed/WidowerDivorced Who else lives with you? (People and animals)* Note: Since another dog in the household will distract our Service Dog, we are only placing Service Dogs in homes that have no other dogs. Type of Home you live in* : ApartmentHouseOther Fenced Yard?* : YesNo Type of Area you live in* : UrbanSuburbanRuralOther Explanation: Type of Area you and your Service Dog will visit frequently* : UrbanSuburbanRuralOther Explanation: List any Medical Condition(s)* : Please enter none if no conditions exist. Disabled?* : YesNo If Yes, How long have you been disabled? How does your disability affect your life and current level of independence?: List the type of activities you want your Service Dog to assist you with Retrieve and deliver dropped items?* : YesNo Fetch Items?* : YesNo Explanation: Turn lights on and off?* : YesNo Assist you in dressing?* : YesNo Assist you in doing the laundry?* : YesNo Go for help in case of an emergency?* : YesNo Open doors?* : YesNo Open drawers?* : YesNo Press elevator buttons?* : YesNo Accompany you in crowded situations?* : YesNo Explanation: What other activities were you hoping your Service Dog would perform? Name of person completing this form and contact information (Phone and email) Salutation*: ---Dr.Mr.Mrs.Ms.
