Please provide the following contact information:
Please provide the following:
Do you have a disability?
YES
NO
Is this application for a minor child?
YES
NO
If a minor child please provide the name of a parent / guardian:
Are you a military veteran?
YES
NO
Do you currently have a Service Dog?
YES
NO
Have you used a Service Dog in the past?
YES
NO
When do you want the dog to begin training?
immediately upon identification
1-3 months
3-5 months
over 6 months from now
What gender of dog do you prefer as your Service Dog?
Male
Female
Doesn't matter
Do you want to find a younger puppy that you are willing to raise for a few months before training?
YES, I want to raise a puppy for a while
NO, I don't want to deal with the dog until it's trained
I could do either for the right dog
What breed(s) of dog have you contemplated, if at all, as your future Service Dog?
Why have you considered those breeds?
Describe the amount of grooming you can handle:
A once-a-week brushing seems overwhelming
I can brush a dog once a week
I don't mind brushing a dog a few times a week
I don't want a dog with long hair that might matt up
I plan to use, and I can afford a groomer - coat type isn't an issue for the
right dog
I plan to use a groomer - but, I can't afford
expensive grooming, so coat type should be easy to maintain
I want a dog with a non-shed coat and I know it will require a lot of grooming,
and I can handle that
just get me the best dog, I will be able to handle what ever coat type it has
Have you read the information on the website about the Dog Locator Service:
YES
NO
Have you read the pre-application information at the website?
YES
NO
What service do you plan to use to have this dog trained as your Service Dog?
T.E.A.C.H. train your own dog
Fully Trained SD training
I don't know yet
I don't plan to use a Committed Canine service
What is your top dollar limit that you can spend to acquire a dog to train as your Service Dog?
This number should include any veterinary care it will need (like neutering) and any transportation costs:
Do you currently have that total amount of money to spend on a dog, if it were to be identified soon?
YES
NO
What sort of tasks do you need a Service Dog to perform to mitigate your disability?
Mobility (Balance / walking)
Mobility (pulling / wheelchair)
Mobility (opening doors, turning off lights etc...)
Retrieving objects
A psychiatric disability (PTSD, panic/anxiety)
An autism spectrum disorder
Medical Response (to seizures, shifts from normal)
Emotional Support
Other
If you chose Other, please describe:
What is the distance you are currently willing to travel to acquire the dog?
I cannot travel at all
50 miles
100 miles
150 miles
200 miles
300 miles
Are you able to travel to Brownstown, IL to receive training on how to handle your new dog?
YES
NO
Describe your ability to impose your will upon someone / something (1= not at all, 5 = no problem)
1
- not at all, that is really hard for me, I can't have a dog that might
challenge my authority
2
3
4
5
- I'm used to taking control of myself and others all the time, I can handle a
dog that might challenge me a bit
Describe any other pets you have in your house (species, gender, age, spay/neuter):
Please add any additional information you want us to know about what sort of dog you hope we locate as your future Service Dog
Will you be able to provide a letter from your doctor stating that you have a recognized disability?
YES
NO
