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*: How will you exercise the dog?* 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 5 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. Is anyone in your household allergic to, or afraid of dogs?* : YesNo If yes, please explain below: 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.
