Committed Canine, Inc.

Application for Fully Trained Service Dog

 

  This is the application for a Fully Trained Service Dog from Committed Canine, Inc.  If you want to apply for the "train your own dog" program (T.E.A.C.H.), please click BACK and choose that option.

There is a $50 application required to be submitted with this application.  Information on how to submit the fee will be provided at the confirmation page, once you hit "send".

 


  1. Please provide the following contact information:

    Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Home Phone
    E-mail
    Repeat E-mail address:
  2. Please identify and describe yourself:

    Date of Birth
    Sex Male Female
    Height provide this information if you require a dog to pull a wheel chair or provide mobility support
    Weight provide this information if you require a dog to pull a wheel chair or provide mobility support
  3. Do you have a disability?

    Yes No

  4. Do you currently employ a Service Dog to mitigate your disability?

    Yes No

  5. Have you ever used a Service Dog to mitigate your disability?

    Yes No

  6. Have you read the Pre-Application information at the Committed Canine Website?

    Yes No

  7. Have you read the information about Fully Trained Service Dogs at the website, including the cost of the service?

    Yes No

  8. Do you believe you are capable of handling a trained Service Dog, including the need for daily training maintenance?

    Yes No

  9. Do you currently have the funds to pay for the training of a fully trained Service Dog?

    Yes No

  10. Would you like to have a dog that you current own professionally trained as your Service Dog?

    Yes No - If No, skip to question 14

  11. What is your dog's breed?


  12. What is your dog's age?


  13. What is your dog's gender?

    Male - intact
    Male - neutered
    Female - intact
    Female - spayed

  14. If you don't have a dog ready to be professionally trained, what breeds interest you as your SD?


  15. Why do you think that breed/breeds would be a good SD for you?


  16. I need a Service Dog to help me with:

    Mobility (balance / walking)
    Mobility (pulling wheelchair)
    Retrieving objects
    A psychiatric disability (PTSD, panic/anxiety)
    Autism
    Alert (Seizure/Medical Alert)
    Hearing Disability
    Emotional Support

  17. Describe your disability:


  18. Describe at least three tasks that you want a dog to learn to mitigate your disability:


  19. Are you able to travel to Brownstown, IL to receive training on how to handle your Service Dog?

    Yes No

  20. Describe your level of self confidence when you must learn something new:

    bad poor average fair good

  21. Describe your level of self confidence once you understand a task and have had some practice:

    bad poor average fair good

  22. How would you rate your ability to impose your will on someone else (1= not at all, 5 = I always win)

    1 2 3 4 5

  23. Have you trained a dog before?

    Never
    A pet, over 5 years ago
    A pet, in the past 5 years
    A Service Dog that I used or still use

  24. Will you take your Service Dog to a current job that you hold outside of your home?

    Yes No

  25. Have you discussed the idea of acquiring a Service Dog with any family or friends with whom you share a home?

    No
    Yes
    Not Yet, but plan to do that
    I do not live with other people

  26. How will you manage your SD for exercise / potty breaks:

    Let out in fenced yard
    Let out in un-secured yard
    Walk on leash
    Let out in enclosed kennel

  27. Please describe any other pets that you have in your home (species, breed, gender, age, etc..)


  28. If you had a Service Dog in the past, how did you acquire the dog?

    An established Service Dog organization
    A private trainer (fully trained dog)
    A private trainer helped me train my own dog
    I trained my own dog without support
    I have never had a SD before

  29. Please use this box to add any further information you may want to offer:


  30. Will you be able to provide a letter from your doctor stating that you have a recognized disability?

    Yes No



Copyright 2011 [Committed Canine, Inc.]. All rights reserved.
Revised: 12/16/12