Application for a service dog for the classroom

Full name:

Address:

City

State

Zip code:

Phone number:

E-mail address::

Date of birth:

Address of employer

Work telephone:

Length of present employment:

How long have you been a teacher/therapist?

Schooling completed:

Describe the children and adults you are working with (include disabilities)

Are there any other animals in your classroom, office or building? If so, please list

Have you discussed this application with your employer?

Yes No

If so, do you have your employers permission?

Yes No

Living arrangements

Do you live in the City, Suburbs, or Rural area?

How long does it take you to travel to work?

How many people live with you?

Name

Relationship

age

Are you or anyone you live with allergic to dogs?

Yes No

Do you live in a house or apartment? 1 level or 2 levels

Do you have a fenced yard?

Yes No

What are your hobbies or interests?

Do you have any other physical limitations such as a back problem, that we should consider when choosing a dog for you?

What types of transportation do you use? (bus, car, van)

Car Bus Van Train Plane

Please list any other information that may be of help to us in selecting the proper dog for you:

Dog information

Have you ever had a dog before?

Yes No

Do you or anyone in your household have a dog now?

Yes No

If so, what is the age of the dog? male/female neutered?

Age:

Sex:

Neutered:

List other pets:

Do you have any dog handling experience? (please explain

Have you attended dog obedience classes? If so, what level?

Do you travel a lot?

Would you take the dog with you on trips?

Yes No

If not, would the dog stay with a family member or in a kennel?

The reason I want an assistance dog is:

Dog Training

All dogs are taught basic dog obedience and socialized in
Public and classroom/office situations. The following are the tasks that a classroom/therapy dog is taught. It will be the teacher/therapists responsibility to incorporate the dog and its tasks into his/her curriculum.

1. Carry articles in a dog backpack
2. Pick up dropped articles
3. Retrieve objects off counters or desks
4. Turn light switches on and off
5. Go to your kennel (house) - to use this task - an area of classroom/office must be provided for the dog's house
6. Catch articles thrown to it (bean bags, etc.)
7. Shake with paw
8. Bark on command

I can arrange to take time off from work/school to come to the Massachusetts center to train with my dog.

Yes No

Are you allergic to cats

Yes No

Do you smoke?

Yes No

** 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!