Committed Canine, Inc.

Please provide the following contact information - if you are filling the application out for someone, please answer the questions for the prospective T.E.A.C.H. student:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Repeat E-mail:

Please identify and describe yourself:

Occupation
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

Are you a US Military Veteran?

Yes No

Are you filling out this application for a minor child who is disabled?

Yes No

If you are not physically or mentally capable of performing the requirements for the T.E.A.C.H. program to train your own dog, do you have a helper who can attend the course to help you?

Yes No

Do you have a disability?

Yes No

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

Yes No

Have you ever used a SD to mitigate your disability?

Yes No

Have you read the Pre-Application information at the Committed Canine website?

Yes No

Please provide any comments or questions you have regarding the Pre-Application information at the website:

Have you read the information about the T.E.A.C.H. program at the Committed Canine website?

Yes No

Please provide any comments or questions regarding the T.E.A.C.H. train-your-own-dog program:

Do you believe that you are physically capable of training your own Service Dog under the guidance of professional instructors?

YES
NO
Not Sure

Do you believe you are mentally / emotionally capable of training your own Service Dog under the guidance of professional instructors?

YES
NO
Not Sure

When would you be interested in participating in a T.E.A.C.H. course?

Within the next month
In 2-4 months
In 4-6 months
6 month or later

Do you / will you have the funds to attend the class at the time you specified you would like to enroll in the T.E.A.C.H. class?

Yes No

Describe your status regarding a the dog you hope to train:

I currently own the dog I want to train
I plan to acquire the dog that I want to train
I need help finding the dog I want to train

If you own the dog, already, please describe it here:

Name
Date of Birth
Sex	Male Female
Breed
Weight	provide this information if you require a dog to pull a wheel chair or provide mobility support
Height at Withers	provide this information if you require a dog to pull a wheel chair or provide mobility support

If you don't have a dog, describe the dog you hope to acquire as your SD:

Breed
Age
Sex	Male Female

Why do you feel that the breed of dog (you have or hope to acquire) will be best suited as your Service Dog:

I need a dog to perform the following for me:

Assist with Mobility (walking / balance)
Assist with Mobility (wheelchair pulling)
Physical Disability
Retrieving Objects
Psychiatric Disability (PTSD, panic/anxiety)
Psychiatric Disability (other)
Psychiatric Disability (Autism)
Medical Alert / Seizure Alert
Hearing Disability
Other

Describe your disability specifically as it applies to the use of a Service Dog that will mitigate your symptoms.

Describe at least three tasks that you expect the dog to perform to mitigate your disability:

Are you able to travel to Brownstown, IL for the T.E.A.C.H. course - which is held on two, 3-day weekends separated by 2-6 months?

Yes No

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

bad poor average fair good

Describe your level of self-confidence once you have learned something new and had time to practice it:

bad poor average fair good

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

Have you ever trained a dog before?

Never, not even a pet
A pet, over 5 years ago
A pet, in the past 5 years
A Service Dog that I used or still use

Will you take your Service Dog to a job that you hold outside your home?

YES
NO
Don't Know

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

No
Yes
No, but plan to do so
I don't live with anyone

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

Let out in fenced yard
Let out in unfenced area
Walk on leash
Let out in pen/kennel
Other

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

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
Other
I have never had a Service Dog before

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

Is there anything else you want to add?