Kingston 4 Paws Service Dogs

Transcription

1 Kingston 4 Paws Service Dogs Wait List Family/Person Application Information outlined in red is required Name of Applicant: Name of Person completing this application: Relation to Applicant: Address of Applicant: Number and Street Apartment/Unit# City Province Postal Code Home Phone: ( ) Cell Phone: ( ) Emergency Contact Name: Emergency Contact Phone Number: ( ) Basic Information about the applicant Applicant s Age: Birth Date: Height: Weight: 1

2 Is the applicant [if a child, the applicant s parent(s)] able to travel to Kingston for our team training? Yes No Is the applicant: in a wheel chair, homebound, in-active, active, very active Applicant s Medical Information What is the primary medical diagnosis? Does the applicant have any other medical problems? (Please explain) Please describe any limitations the applicant experiences in everyday life: Does the applicant have any developmental delays or speech delays? If yes, please describe: 2

3 What type of medical equipment does the applicant use on a daily basis? (e.g. wheel chair, crutches, braces, hearing aids, etc.): Does the applicant have any safety measures that must be kept in place as a result of the applicant s diagnosis? If yes, please explain: Has the applicant ever shown aggression towards an animal? If yes, please explain: Information about the applicant s home What type of home does the applicant live in (apartment, condo, house, etc.)? Is this home rented or owned? Does anyone in the applicant s home have allergies to dogs? If yes please explain who and to what types of dogs: Who else lives at the applicant s home? Name: Age: Relationship: Name: Age: Relationship: 3

4 Name: Age: Relationship: Name: Age: Relationship: Other: Does the home have a fenced yard? Yes No If no, where do you plan to exercise a dog? Does anyone else in the household have a disability? If yes, explain: Yes No What other animals live in the applicant s home? Type: Age: Spayed/Neutered? Yes No Type: Age: Spayed/Neutered? Yes No Type: Age: Spayed/Neutered? Yes No Type: Age: Spayed/Neutered? Yes No Other: 4

5 Are there any other domestic animals that live outside at the applicant s home/yard? If yes, please describe: Have you ever had to give up a pet? If yes, please explain: Yes No Does the applicant (or family) currently have a veterinarian they use? Yes No, if yes, please indicate: Doctor s name: Name of Clinic: Address: Phone number: ( ) May we contact the vet? Yes No Has the applicant or anyone in the home ever been convicted of animal cruelty or neglect? Yes No If yes, please explain: 5

6 Do you have strong feelings about what traits you like or dislike in a dog? Yes No If yes, please explain: Additional Applicant Information All applicants under the age of 18 MUST be accompanied by an adult to our team training classes. Who will attend team training if applicant is under age or needs assistance? Is the applicant employed or attending school? employed, student, neither Would it be helpful for the trained service dog to attend school or work with the applicant? Yes No May we contact the employer or school? Yes No Name of Employer/School: Address of Employer/School: Contact Person and Phone Number: Have you or the applicant ever applied for, or received a service dog from another organization? Yes No Name of organization: When: 6

7 Outcome of that application: Is the applicant able to handle a dog alone? Yes No Don t know Can the applicant feed a dog alone? Yes No Don t know Can the applicant walk a dog alone? (must be over 14) Yes No Can the applicant groom a dog? Yes No Don t know Can the applicant verbally communicate with a dog? Yes No Can the applicant give hand signals to a dog? Yes No If No to any of the above, who would help the applicant with a dog? What tasks could a service dog do that would help the applicant become more independent? In what areas does the applicant experience difficulties? Picking up dropped items Carrying items Turning on/off lights Retrieving the phone Poor balance Sensory processing problems Opening doors Getting up from floor Getting up from sitting Moving a wheelchair Up or down stairs Spatial transitions/ locations 7

8 Applicant s or Caregiver s Ongoing Commitment Please check which of the following you can commit to: providing: Veterinary Care (including annual check-ups and emergency visits) Heartworm medicine (monthly) Flea Control Weekly grooming 80 to 120 hours of handler and customized dog training regular post- graduation training as required Please describe the applicant s current support system. Who would care for the service dog if the applicant were to become injured, in the hospital, otherwise unable to care for the dog, or in an emergency? Other Is there anything else that we should know in order to train a dog specifically for this applicant? How did you hear about our organization? 8

9 Please identify three non-family members who will complete our on-line Program Applicant Reference Form (please direct them to complete the online form at reference.k4paws.ca): Name: Relationship: Name: Relationship: Name: Relationship: The following, if applicable, are required to be submitted with your application before it will considered: 1. A recent detailed letter from a medical professional (MD,RNP or equivalent) stating what all of the applicant's diagnosed medical conditions are and explaining why they could benefit from being partnered with a service dog. 2. If the dog is for someone over 18 with mental health challenges, please include a letter from a medical doctor stating that you are receiving ongoing treatment for your condition and pose no threat to a service dog. 3. Applicant reference forms from the three non-family members listed above. 4. $75 non-refundable application fee Acceptance of the Conditions of Application By signing below I hereby acknowledge that I have read and responded accurately to the questions and information requested herein. I understand that Kingston 4 Paws Service Dogs (K4PSD), at its sole discretion, has the right to deny service to an applicant for any reason including, but not limited to, failure to meet the established criteria for receiving a service dog, or K4PSD s inability to train a service dog to address the needs of the applicant. I understand that K4PSD also reserves the right, at its sole discretion, to remove a K4PSD service dog from a home at any time for mistreatment/ neglect or an inappropriate match. I understand that when a dog is placed with an applicant they become responsible for, and can afford, all the continuing costs related the dog's care which will exceed $1,200 per year. I understand that K4PSD also reserves the sole right to cancel an application at any time, without cause or return of fees paid. I declare myself to be physically and mentally able to participate the K4PSD training I will require in order to properly care for and maintain the service dog entrusted to me or the applicant. My family, members of my household and myself waive ours rights and any claims for damages and/or injuries, which may occur in connection with our participation in any K4PSD programs. 9

10 Signature of Applicant/Caregiver: Date: Click the box if you can sign digitally Signature of Guardian (if applicant is under 18 years): Date: Click the box if you can sign digitally If you have the ability you may sign this application digitally at this time. Otherwise submit it on-line unsigned, then print and sign the signature page manually and either scan and this page to or mail or deliver it to our office. Regardless, please date your application before you submit it. Thank you for taking the time to fill out our Kingston 4 Paws Service Dog application. We will do our best to get back to you as soon as possible. The current wait time to receive a K4Paws Service Dog is approximately 24 months. Please send completed applications to: [email protected] or mail to: Kingston 4 Paws Service Dogs 1057 Hickorywood Cr. Kingston, ON K7P 2E6 (613)