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Full name:
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Address:
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City
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State
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Zip code:
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Phone number:
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E-mail address::
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Date of birth:
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Occupation:
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Place of business
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Days and hours employed weekly:
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Work telephone:
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If you volunteer, list your weekly commitment:
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Have you discussed this application with your employer?
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Yes
No
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If student, please list school name,
address and current grade:
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School name:
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School address:
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Current grade:
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If student, have you discussed this application with
your school's principal?
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Yes
No
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Schooling completed:
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Name of friend or relative we can call if we could not
reach you:
(if applicant is minor, list parent or guardian)
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Name:
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Phone:
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Relationship:
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Brief history of your disability:
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If you have had a spinal cord injury, please list the
date of the accident and your spinal classification (C7 etc.)
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Please describe your upper body strength, especially the
arms (range of motion) and hands (grip and dexterity).
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Is one side (left or right) stronger?
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Do you bruise easily? Could a dog put his front legs
up on your lap without hurting you?
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Do you have spasms in your arms or legs? Yes
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Yes
No
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Is it difficult for you to function in hot weather-or
cold weather?
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Have you discussed this application with your doctor?
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Yes
No
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Name of your physician:
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City of physician:
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State of physician:
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Address of physician:
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Phone of physician:
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Living arrangements
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Do you live in the City, Suburbs, or Rural area?
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Please describe your neighborhood (busy road, neighbors
close by, dogs/cats running free-examples)
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How many people live with you?
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Name
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Relationship
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age
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Do you employ a personal care attendant?
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Yes
No
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Do you use more than one PCA?
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Yes
No
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If so, what hours do they assist you?
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What tasks do they do, or aid you to do?
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Will you be bringing your personal care attendant with you during
your training session at the NEADS center?
*Please NOTE: NEADS does not provide personal care attendants and
no staff member is trained as a PCA.
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Yes
No
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If you are bringing a PCA, can your attendant stay
with you in the same bedroom?
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Yes
No
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If space is a problem, can your PCA stay in a room
on a different floor of the house?
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Yes
No
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If so, will a sound monitor be necessary?
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Yes
No
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Do you need assistance with your activities of daily
living (ADL)?
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Yes
No
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Do you live in a house or apartment? 1 level or 2 levels
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Do you own or rent? Rent
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Rent
Own
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If you live in an apartment ,what floor do you live on?
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How many units are in your building?
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If renting, have you discussed this application with
your landlord?
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Yes
No
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Do you have a fenced yard?
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Yes
No
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Could you put up a trolley run in your yard?
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Yes
No
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Do you have many visitors?
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Yes
No
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What are your hobbies or interests?
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Do you have any other physical limitations such as sight
or hearing loss that we should consider when choosing a dog for you?
(please note that Balance dogs do not perform any guiding of the blind.
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What types of transportation do you use? (bus, car,
van)
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Car
Bus
Van
Train
Plane
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Please list the equipment that you use for your disability
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If you use both a manual and power wheelchair, please
explain the situations in which each one is used.
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Do you self transfer?
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Yes
No
N/A
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Please list any other information that may be of help
to us in selecting the proper dog for you:
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Your training with the dog
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I can arrange to take time off from work/school to
come to the Massachusetts center to train with my dog.
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Yes
No
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Is fatigue a factor in your daily life?
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Yes
No
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Do you need to have rest periods during the day?
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Yes
No
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Do you smoke?
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Yes
No
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Dog information
A successful Balance Dog applicant must be able to care
for the daily need of his or her dog. Therefore we ask you to consider
and answer the following: (Please indicate if you are unable to do a
certain task.)
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Where will you dog be taken for toilet requirements?
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When do you get out of bed in the morning?
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What time do you retire for the evening?
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| Who will help with the dog's care if you are sick or cannot
get outside? |
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Helpers name:
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Helpers phone:
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Where will the dog be exercised and have playtime?
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Is there a particular type/breed dog that you do not
like?
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Have you ever had a dog before?
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Yes
No
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Do you or anyone in your household have a dog now?
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Yes
No
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If so, what is the age of the dog? male/female neutered?
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Age:
Sex:
Neutered:
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List other pets:
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Would you take your dog to work, school (if appropriate),
social events?
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Yes
No
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If not, where would the dog be?
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Do you travel a lot?
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Would you take the dog with you on trips?
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Yes
No
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How many hours per day would the dog be alone?
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When would you be able to start training with your
Balance Dog?
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The size of dog I'd prefer:
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The reason I want an Balance Dog is:
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Dog Training
All dogs are taught basic dog obedience and socialized
in public situations.
What tasks do you want your dog to accomplish for you?
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Carry articles in a dog backpack for you?
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Yes
No
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Pick up dropped articles for you?
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Yes
No
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Retrieve objects off counters or tables?
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Yes
No
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Turn light switches on and off?
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Yes
No
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Stand and brace for balance?
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Yes
No
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Other tasks you wish us to consider:
** Please review the information
you have provided. You will not be given an opportunity to edit this
information, after you click the submit button.
Thank you!
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