In-Home Assistance Dog Application - Circle Tail

Most fields are required. If a required field does not apply, insert NA.

Name *

First

Last

Age *

Phone (Primary) *

Phone (Secondary)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Person Completing Application *

First

Last

Relationship to Applicant *

Age *

Phone (Primary) *

Phone (Secondary)

Email *

Do you live within 75 miles of Circle Tail or within Ohio? *

Yes
No

Description of disability: *

How long has the Applicant had the disability? *

Is your disability stable? *

Yes
No

Please describe any recent exacerbation in your condition. *

Describe Applicant’s limitations in detail including verbal/hearing/cognitive/mobility/mental health, etc. *

List the activities you expect a service/hearing dog to help Applicant with. *

What are the 2 most important activities for which help is needed? *

Is there an outside caretaker involved with Applicant’s care? *

Yes
No

If so, please explain the duties of the caretaker. *

Dog Gender Preference *

Male
Female
No Peference

Dog Size Preference, check all that apply: *

Small (15 - 30 lbs)
Medium (30 - 60 lbs)
Large (60 - 90 lbs)
No Preference

Breed Preference: *

Indicate any breeds you do not prefer: *

What breed(s)/ type(s) of dogs have you had responsibility for as the primary caregiver, and how long did you have each of them? *

What pets live in the home currently (please include names). *

Do you have a Vet? *

Yes
No

Vet's Name *

First

Last

Vet's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Vet's Phone *

Number of people in household, including Applicant: *

Ages of children under 18 yrs. old in household: *

Who will be the dog's primary caregiver: *

Does the Applicant or any family members/caretakers smoke? *

Yes
No

Does any other person in the home have any mental health or physical disabilities? *

Yes
No

If yes, please describe. *

Applicant lives in a: *

Town/City
Suburb
Rural Area

Applicant resides in a: *

House
Mobile Home
Apartment
Condo

Is the Applicant's housing rented? *

Yes
No

Landlord's Phone *

Landlord's Name *

First

Last

Is yard for dog fenced? *

Yes
No

Approximate square feet fenced? *

Is fence: *

Electric
Wire
Electric

If fence is solid, how high is it? *

If Applicant's household will have visitors over, check all that apply:

All the time -- household has a revolving door
A lot
Sometimes - occasional friends and family over
Rarely - doorbell doesn't work

Number of hours per day the dog will be routinely left alone: *

Describe where the dog will be when the Applicant is not home: *

Describe where the dog will be when the Applicant is sleeping: *

How much training is the Applicant willing to do? *

Willing to do no training
Willing to do some training
Willing to do a lot of training

Comments:

Does the Applicant mind house training a dog? (Please understand that any dog may have accident or two while adjusting to a new environment.) *

Yes
No

Comment

Is the Applicant comfortable doing training with the dog to improve manners such as jumping, stealing food, and pulling on the leash, etc.? *

Yes
No

Comment

Is the Applicant comfortable doing training with the dog to maintain/improve obedience and advanced skills? *

Yes
No

Comment

How much is expected to be spent yearly for the care of the dog, including food, medical care, boarding, grooming, toys, heartworm, and flea control, etc. per year? *

How will the Applicant provide DAILY exercise (at least one hour per day) for the dog? Please consider living arrangements, physical condition, and seasonal weather conditions. *

If there is additional training required for the In Home Service/Hearing/Companion dog, it is agreed the training will be completed at Circle Tail (or as otherwise directed). *

Yes
No

Any additional comment?

Custom Captcha *

=

this is widget test