service dog application … · web viewall application materials will become the property of...

SDI keeps your

entire application confidential.

All application materials will become the property of Service Dogs, Inc.

Completed Client Application Checklist:

$50 Non-refundable Application Fee Client Application Form* Signed Background Check Authorization Two Letters of Recommendation from non-family individuals For Non-Active Military Only: A Copy of Your DD214 Form Required signatures.

o Sign both application and background check where shown. o Keep a copy for your records

Return this complete and signed package. (Please note: Incomplete or unsigned packets cannot be processed.)

MAIL TO: Service Dogs, Inc. Attn: Applicant Coordinator 4925 Bell Springs Rd. Dripping Springs TX 78620

*Attach additional sheets as needed for any answer.

CLIENT INFORMATION Date (mm/dd/yy)

STEP 1: Submit a client application (this packet)

STEP 2: If our program matches your needs, SDI will request two additional items: 1) Medical form completed by your physician or therapist 2) Photo or video essay based on an outline SDI provides.

STEP 3: SDI will invite qualified applicants to attend Applicant Orientation at our Training Center.

STEPS TO APPLY TO SERVICE DOGS, INC. (SDI)

Service Dogs, Inc. (SDI) Client Application

First Name MI Last

Address City

County ST Zip

Cell Phone E-mail

(Please note, SDI applicants must have an active cell, text and email account.These are our primary means of communication with applicants and clients.)

Hm Phone Wk Phone

Age (must be 25 or older) Birth date (mm/dd/yy)

Marital Status Sex Weight

Nearest Relative/Caregiver

Name Relationship

Address

City State Zip

Cell Phone Work Phone

This application must be IN THE WORDS OF THE PERSON WHO WILL USE THE DOG. If writing is difficult for you, provide the name and relationship of person transcribing your words below.

Name Relationship

How did you learn about SDI?

Military Personnel Only:

Do you have a military affiliation?

What branch?

Are you active or retired?

For non-active military clients, please attach a copy of your DD214 to this application.

DISABILITY PROFILE AND ASSISTANCE NEEDS

[Type here] [Type here] Page 1 of 15Service Dogs assist people with primary mobility challenges, such as Multiple Sclerosis, muscular dystrophy, arthritis, amputation, stroke, or spinal cord injury.

Hearing Dogs alert people who are deaf, hard of hearing or hearing impaired to sounds.


Which type of dog are you applying for?

Service Dog A service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access. Clients must be 25 years of age or older and capable of handling the dog in public without assistance.

Hearing Dog A Hearing Dog is trained to alert a hearing impaired person to sounds by touching them, then leading them to the sound when cued. The dog is granted full public access. Clients must be 25 years of age or older and capable of handling the dog in public without assistance.

________________________________________________________________________

What is your disability?

Do you have any other medical conditions, including mental health diagnosis?

Yes No If yes, please describe.

How long have you had your disability?

If your disability was caused by injury, what progress have you made post injury?

Are you in or have you completed rehabilitation? Yes No

If yes, please describe, including frequency, duration and type of therapy: [Type here] [Type here] Page 2 of 15

Service Dogs assist people with primary mobility challenges, such as Multiple Sclerosis, muscular dystrophy, arthritis, amputation, stroke, or spinal cord injury.

Hearing Dogs alert people who are deaf, hard of hearing or hearing impaired to sounds.


Please indicate the devices that you use:

Wheelchair: manual power both 3-wheel electric scooter

Walker Crutches Other

Which do you use most often?

Do you drive? Take bus? Cab? Other? (List)

Please describe any other assistive devices you use, such as wheelchair ramp, lifts, prosthesis, cane, TTY, etc.

[Type here] [Type here] Page 3 of 15


STRENGTHS AND ABILITIESPlease rate your abilities using a 1 to 10 scale.

Mark any aids you use:

Rating AbilityHearing? Hearing Aid ASL Lip Reading Other (List)

Speech? ____ Easily understood ____ Tone variation ____ Volume

Do you use a word board? Yes No

Other device speech/hearing device? (list)

Vision? Do you use corrective lens? Yes No

If yes, do you have 20/20 vision with correction? Yes No

If you need additional visual assistance (large font, note taker, etc.) please describe:

Learning Ability? Need assistance (list/describe)

Is falling a concern for you? Yes No

If yes, how often do you fall? Describe how you fall (like a tree, etc.), what commonly causes you to fall, and how you recover.


No Use Full Use1 2 3 4 5 6 7 8 9 10


Please rate with one number for each limb below.

No Use Full Use1 2 3 4 5 6 7 8 9 10

Left Side Rating

Right Side Rating

Hand Strength

Dexterity

Arm Strength

Arm Reach/Extension

Upper-Body Strength

Leg Strength

Leg Control

How do you handle the following?

Routine medications By yourself Assisted Provided by others

Your finances, checkbook By yourself Assisted Provided by others

Driving By yourself Assisted Provided by others

Housecleaning By yourself Assisted Provided by others

Meals By yourself Assisted Provided by others

Getting dressed By yourself Assisted Provided by others

Shopping, groceries, etc. By yourself Assisted Provided by others

Personal Care By yourself Assisted Provided by others

Email/Cell Phone use By yourself Assisted Provided by others

What personal attendants (including family members) do you use? Personal Care Aide Cooking Cleaning Medical Other ___________

Describe how many attendants and how often? (Daily, weekly?)



What is the medical outlook for your condition in the next 3-5 years?

Please describe any other limitations – common challenges you experience, mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, your ability to read and understand written material - anything that might help us understand your needs.



PERSONAL AND WORK ENVIRONMENT

What work, school, or rehabilitation program(s) have you completed or are you attending?

What is your current work or school schedule?

What are your plans for work or school?

How many times a week would your dog accompany you in public?

Please list typical locations where your dog would go with you:

If you participate in sports, clubs, social groups or other special activities where your dog would accompany you, please list them.

Where would your dog NOT accompany you?



List the names and ages of the people living in your home and/or taking care of you on a daily basis, including their ages and their relationship to you.

Name Relationship Age

Do any other members of your household have a physical or mental disability? Yes No

If so, how are they disabled and what are their limitations?

Please describe your home and yard:

If you have a yard, is your yard fenced? No Yes

If yes, how tall is the fence?

What material is your fence, i.e. wood, wire, etc?

If you do not have a fenced yard, please describe how and where you will toilet your dog and exercise your dog. It will need to toilet multiple times daily regardless of weather conditions and exercise 30-60 minutes daily.



What pets do you have now? Describe and list type, breed, size and age.

Please list your veterinarian’s name and phone number.

Have you ever given a pet away or placed a pet in a shelter? Yes No If so, why and what happened to it?

Have you had a dog before? Describe what kind, your age at the time, any training you did, and what became of it.



LIVING WITH A HEARING OR SERVICE DOGAn SDI dog must be the only dog in the home. If you have another, dog, are you willing to rehome your dog? Yes No If yes, please explain where and how you will rehome.

Having a cat may delay our ability to match you with a Service or Hearing Dog but is not prohibited. If you have a cat, are you willing to rehome your cat? Yes No If yes, please explain where and how you will rehome.

On a daily basis, how will you handle walking, clean-up after toileting, feeding, medicating, exercising, and grooming your SDI dog?

How will you handle the care of your SDI dog if you are hospitalized?

Can you commit to attending the following meetings at our Training Center in Dripping Springs, Texas at your own travel and lodging expense?

Applicant Orientation Day (1 day, 9AM – 4PM) Yes No Matching - to meet dogs (one or more 2 hour sessions) Yes No Team Training Week (9AM – 4PM, Mon-Fri) Yes No

Please explain any No answer



Can you restrict your calendar/activities to accommodate an initial 30-day bonding period? This is an intense training, learning and relationship-building period key to success. Yes No Please explain any No answer

We estimate the cost of care for a service dog is approximately $2000 per year. Are you able to take on this cost? Yes No Please explain.

A good basic estimate for the cost of an SDI dog at $2000 per year based on the cost of food, treats, toys, accessories, annual vet checkup, vaccinations, and a small stipend for unexpected veterinary occurrences. However, serious veterinary issues can arise.

You routinely play fetch to exercise your dog. It suddenly starts limping, so you stop¸ but later your dog continues to limp and cannot put any weight on one leg. Your vet diagnoses a torn ligament requiring surgery – a not uncommon injury in large dogs. The cost will be anywhere from $2,500-$3,000 for surgery and post-operative expenses. Please describe how you would proceed.



DO YOU AGREE TO THE FOLLOWING CONDITIONS REQUIRED TO RECEIVE AND RETAIN AN SDI DOG?

That there is a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years. Yes No Please explain either answer.

That an SDI dog will spend most of it time with its partner at home AND at work, at school, and social events and that it will NOT be in a yard or kennel or home alone for long periods of time. Yes No, explain

That an SDI Dog is not a family pet – it has a specific function in the partner’s life and minimal interaction with others. Yes No, explain

That you and your dog are ambassadors for Service Dogs, Inc., as well as for the entire assistance dog industry, and you are required to maintain your dog’s appearance and manners, as well as your handling skills for the working life of the dog. Yes No, explain

That you assume full responsibility for maintaining appropriate training and behavior, annually updating your public access certification with an SDI evaluator and understand that SDI may reclaim the dog if you do not do so. Yes No, explain

That an SDI dog cannot be allowed off leash except in a secure area. Exercise and elimination must be done on leash or in a fenced yard or dog run. Yes No, explain



That you must assume full responsibility as caretaker of your SDI dog, in charge of its safety, health and welfare and that failure to do so can result in SDI reclaiming the dog. These needs include:

Medical care – all care prescribed by your veterinarian and routine annual care as directed by SDI. Yes No, explain

Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight. Yes No, explain

Daily exercise and play Yes No, explain

Cleaning up -- when your dog toilets in public and repairing any damage caused by your dog. Yes No, explain

Repair of Damage -- repairing or paying for any damage caused by your dog to others property. Yes No, explain

Sign below if you agree to the conditions listed above. Attach additional sheets if needed to explain any answer.

Signature Required Date



Background Check AuthorizationIn order for us to process your application, we need a completed background check. Please fill out the information below. We will run the background check for you and destroy the sheet containing your SSN. Please type or print clearly.

First Name Middle Last

Address

City ST Zip

County Move in date

E-mail Date of Birth

Social Security # Gender

If you have had another address in the last 5 years, please list below:

Address

City ST Zip

County Move in date

Have you ever been convicted of a crime? A conviction will not necessarily bar you from receiving a dog. Yes No If yes, please describe:

Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process. I hereby authorize Service Dogs, Inc. (SDI) to investigate my background for purposes of evaluating my application for a service dog. I understand that Service Dogs, Inc. will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation through companies chosen by Service Dogs, Inc. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application will not be processed further.

Signature Required: Date:



Letters of Recommendation

Please list the names and contact information of two people who will provide letters of recommendation for you. We will need a physical letter from each included with the application or sent separately to Service Dogs, Inc.

Your application will not be reviewed until these letters are received. 1) Personal (not a relative)

2) Professional (Co-worker, counselor, pastor, social worker, etc.)

Personal (non-relative)

First Name Last Name

Address

City ST Zip

Cell Phone E-mail

Professional (Co-worker, counselor, pastor, social worker, etc.)

First Name Last Name

Address

City ST Zip

Cell Phone E-mail

Please include the letters in this packet or send letters of recommendation to:

Service Dogs, Inc., Inc.Attn: Applicant Coordinator

4925 Bell Springs Rd.Dripping Springs TX 78620


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