ADASDF places a limited number of trained service dogs with those who qualify for a service dog at no charge for the dog to the applicant. You will have to have the financial ability to properly care for and provide for the dog. You will have to have the financial ability to come to our location in Wisconsin and stay for one week or more, depending on your needs, while you train with the dog. The application below is a preliminary application and there will be a more in-depth medical history required from your physician with letter of recommendation after reviewing the preliminarily application. There is a non-refundable ten dollar processing fee to be submitted with the application. We have a policy to not place one of our service dogs in a home that already has a dog/dogs in it. There is the exception in the case were there is already a service dog in place and for health reasons is not able to work for you anymore. We will consider placement in that home. Please copy the below application into a word processor, answer all the questions, enclose a ten dollar application fee, and mail to: ADASDF Att: LH-Service Dog Application N3710 Hwy F & 2nd Street Weyerhaeuser, WI54895 You may email me to let me know your application is being sent by mailed email address is active2@indianheadtel.net attention - Linda You can also download/print the application as a PDF or Word document. ADASDF SERVICE DOG APPLICATION Today's Date____________ Person who is filling out this application___________________________ Have you ever had the use of a service dog ____________ Personal Information- Legal Name Title Street Address City STATE ZIP County Home Phone Cell Phone Email Address Marital Status DOB(age) Height Weight Personal References (Name, Address, Phone, Relationship to you) 1. 2. 3. · Vet Reference of the vet that will be your dog’s primary veterinary. · Nearest Relative to you-Name & Phone · Nearest Neighbor to you-Name & Phone · Education Annual Income · Profession/Occupation Work Phone · Does your employer know you are applying for a service dog? · Will you be taking your service dog to work? · How does your employer feel about the presence of a service dog at work? · Name of person who is your work supervisor. · Do you have any type of criminal record, if so please describe. · Describe yourself; hobbies, activities, clubs, and interests. · What is an average daily routine for you. Health Information- 1. Are you a disabled veteran who became disabled during time in the service? 2. Describe your disability and how you became disabled. 3. How does your disability affect your daily life? 4. Do you have multiple disabilities, if so please list them and how they affect you. 5. Do you smoke? 6. Are you assisted by other persons? 7. Do you use any type of aids such as wheelchair, walker, prosthesis, braces, other? 8. Do you now have a service dog or have you ever had a service dog? 9. List your Primary Care Physician and phone number. 10. Do you take medications? If so how do they help or affect you? Living Situation- - Do you live alone? If no please list whom you live with and their ages.
- Is anyone you live with allergic to animals?
- How do the people you live with feel about a service dog?
- Do you live in Apartment or House? Do you own or rent?
- If renting please list your landlord and phone number.
- How long have you lived at your present address? If less than 5 years list previous also.
- Do you have a fenced in yard?
- Where will the dog be able to relieve themselves?
- Do you have any other animals living with you, if so what are they?
Task for Service Dog- - How could a service dog benefit you and what are you expecting from a service dog?
- What tasks could a service dog perform that would be of benefit to you and assist you?
- What is your primary and or secondary purpose for a service dog?
| 
ActiveDogs