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Application for a NEADS Social Dog for an Individual
Full name:
Address:
City
State

Zip code:
Phone number:
E-mail address::
Date of birth:
Occupation:
Place of business
Days and hours employed weekly:
Work telephone:

If you volunteer, list your weekly commitment:

Have you discussed this application with your employer?

Yes No
If student, please list school name, address and current grade:

School name:

School address:
Current grade:

If student, have you discussed this application with your school's principal?
Yes No
Schooling completed:

Name of friend or relative we can call if we could not reach you:
(if applicant is minor, list parent or guardian)

Name:

Phone:
Relationship:

Brief history of your disability:

If you have had a spinal cord injury, please list the date of the accident and your spinal classification (C7 etc.)

Please describe your upper body strength, especially the arms (range of motion) and hands (grip and dexterity).

Is one side (left or right) stronger?  

Do you bruise easily? Could a dog put his front legs up on your lap without hurting you?

 

Do you have spasms in your arms or legs? Yes
Yes No
Is it difficult for you to function in hot weather-or cold weather?
Have you discussed this application with your doctor?
Yes No
Name of your physician:
City of physician:
State of physician:
Address of physician:
Phone of physician:

 

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

Please describe your neighborhood (busy road, neighbors close by, dogs/cats running free-examples)

How many people live with you?
Name
Relationship
age

 

Do you employ a personal care attendant?
Yes No
Do you use more than one PCA?
Yes No
If so, what hours do they assist you?

What tasks do they do, or aid you to do?

Who will be your third party facilitator?

Can your facilitator stay with you in the same bedroom?

 

Yes No

If space is a problem, can your facilitator stay in a room in a different section of the house?

 

Yes No
If so, will a sound monitor be necessary?
Yes No

In case of a person with very specialized equipment or a child who would be distressed by the campus living arrangement, would a daily commute from home to training be more advantageous?

 
Yes No
Are you or anyone you live with allergic to dogs or cats?
Yes No
Do you live in a house or apartment? 1 level or 2 levels
Do you own or rent? Rent
Rent Own

If you live in an apartment ,what floor do you live on?
How many units are in your building?
If renting, have you discussed this application with your landlord?
Yes No
Do you have a fenced yard?
Yes No
Could you put up a trolley run in your yard?
Yes No
Do you have many visitors?
Yes No

What are your hobbies or interests?

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 service dogs do not perform any guiding of the blind. )
What types of transportation do you use? (bus, car, van)
Car Bus Van Train Plane

Please list the equipment that you use for your disability

If you use both a manual and power wheelchair, please explain the situations in which each one is used.
Do you self transfer?
Yes No N/A

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

 

Your training with the dog
I can arrange to take time off from work/school to come to the Massachusetts center to train with my dog.
Yes No
Is fatigue a factor in your daily life?
Yes No
Do you need to have rest periods during the day?
Yes No
Do you smoke?
Yes No

 

Dog information

A successful assistance 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.)
Where will you dog be taken for toilet requirements?
When do you get out of bed in the morning?
What time do you retire for the evening?
Who will help with the dog's care if you are sick or cannot get outside?
Helpers name:
Helpers phone:
Where will the dog be exercised and have playtime?
Is there a particular type/breed dog that you do not like?
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:
Would you take your dog to work, school (if appropriate), social events?
 Yes No
If not, where would the dog be?
Do you travel a lot?
Would you take the dog with you on trips?
 Yes No
How many hours per day would the dog be alone?
When would you be able to start training with your assistance dog?
The size of dog I'd prefer:

The reason I want an assistance dog is:

Please review all information provided. There will not be an opportunity to edit this application once the submit button is clicked. Thank you.