In Home Service/Hearing/Companion Dog

Date: (click on field for calendar)

Name of Applicant: Age:
(The Applicant is the person needing an In Home dog.)

Street Address:

City & State:   Zip Code:

Primary Phone: Cell Phone:

Email Applicant regularly checks, if any:

Name of Person Completing Application: Age:

Relationship to Applicant:  

Primary Phone: Cell Phone:

Email that you regularly check:

Does the Applicant live within 75 miles of Circle Tail or within Ohio?   Yes No

Description of disability:

How long has the Applicant had the disability?

Is the disability stable? If not, please describe recent exacerbation in 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?
If so, please explain the duties of the caretaker.

Dog Gender Preference:   Male Female 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):

Veterinarian's Contact Information:

Vet Name & Address:

Vet Office 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?

Does any other person in the home have any mental health or physical disabilities? If yes, please describe.

Applicant lives in a:   Town/City Suburb Rural Area

Applicant resides in a:   House Mobile home Apartment Condo

If Applicant's housing is rented, please provide the following information.
Please insert NA in each box, if you do not rent.

Is yard for dog fenced:   Yes No   (If no fence, insert NA in the following 3 questions.)

If yes, approximate square feet fenced:
If yes, is fence solid, wire or electric?
If fence is solid how high is it?

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?

Does the Applicant mind house training a dog? (understand any dog may have accident or two while adjusting to new environment)   Yes No

Comments:

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

Comments:

Is the Applicant comfortable doing training with the dog to maintain/improve obedience and advanced skills?
Yes No

Comments:

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.

In Home Service/Hearing/Companion Dog Adoption Agreement

I have read this form and by signing below, I understand and agree to the following:

Is the Applicant able to travel to Circle Tail (north east side of Cincinnati) for an interview and/ or any training sessions that may be required prior to and following partnership with an In Home Service/Hearing/Companion dog?
Yes No

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

By typing "yes" in the following box and submitting this document, I affirm the foregoing questions have been accurately answered and I agree to all foregoing terms and conditions:

Please provide any additional comment you wish:

Please click the Submit button only once. It takes a few seconds for the form to be processed.