Fill out this application, print,
then mail with the $25 application fee and mail to: California Canine
Academy/Assistance Dogs, 5659 W. Brooks Rd, Merced, CA 95341.
Also, please have your doctor
complete a Medical Background Form, which will then need to be completed and
returned to: California Canine
Academy/Assistance Dogs, 5659 W. Brooks Rd, Merced, CA 95341.
California Canine Academy Assistance Dogs
Application Form: Assistance Dog
Section I: Background
Name:
Address:
City:
Zip:
E-Mail Address:
Home phone:
Work phone:
Your age:
Spouse's Age:
Employer:
Spouse's Employer:
Work Days and Hours:
Sunday
From to
Monday
From to
Tuesday
From to
Wednesday
From to
Thursday
From to
Friday
From to
Saturday
From to
Please give the name of a friend or relative we can call if we can't
reach you:
Name:
Relationship:
Phone:
Work phone:
Are you or anyone living with you allergic to dogs?
Yes No
If yes, who is allergic and
to what extent?
Describe your disability:
Number of years disabled:
Cause
of disability:
Section II: Home
Marital status:
Single
Married
Divorced
Separated
Widowed
How many people live with you?
Please list the people who live with you:
Name
Age Relationship:
Current living arrangement (check all that apply):
Live independently
Live with
parents
Live with
attendant
Others
In a house
In an
apartment
In trailer home
In group
housing
If you use attendant(s), who pays his/her wages?
Are you currently receiving government benefits?
Yes No
Do you use a wheelchair?
Yes, manual
Yes, power
No
Please describe other specialized equipment you use (mouthstick, van
lift, special car keys, etc.):
Please list any additional health problems (e.g. diabetes, epilepsy,
cerebral palsy, etc.):
Describe your leisure activities (TV, visit friends, team sports,
shop, travel, computers, eat out, etc.):
If you are a student, where
do you attend school?
Section IV: Pet History
Have you ever had a dog?
Yes
No
Do you have a dog now?
Yes
No
If yes, what kind?
How old is the dog?
Please list any other pets
you have now:
Section V: Living with a Service
Dog
A service dog needs daily
training, attention, love and care. Do you commit to provide the
following:
Veterinary care?
Yes No
Recommended food?
Yes No
Heartworm medicine?
Yes No
Flea control?
Yes No
Weekly grooming?
Yes No
Emergency care?
Yes No
Do you also commit to the following:
Yes No
Prepare for
and participate in a one hour training session in your home with the
trainer, two times each week.
Yes
No
Follow the
trainer's instructions on feeding, housebreaking, and bathing.
Yes No
Practice
training with the dog ("homework") 15 minutes each day.
Yes No
Treat the dog
as a working dog, not just a pet. That means not allowing strangers to
pet the dog in public without your permision, making the dog behave in
public, and being the only person in your family responsible for the
dog's care.
Yes No
Keep the dog
in good health. That means taking it to the veterinarian when
necessary, giving the dog heartworm preventative (chewable
tablet-monthly kind or daily kind), treating the dog, your home and
yard for fleas in flea season, anything else necessary for the good
health of the dog.
Yes No
Telling the
trainer if you or the dog are having any problems with training,
obedience or any other questions.
Will the dog travel with you?
All the time
Sometimes
Never
Do you plan to take the dog
to your workplace?
Yes No
Do you consider yourself
knowledgeable about dogs?
Yes No
Do you have strong feeling
about what traits you like and dislike in dogs?
Yes No
If so, what are they?
Are you willing to adapt
your lifestyle and/or attitudes to meet your dog's ongoing physical
and psychological needs (e.g. a service dog lives indoors full-time)?
Yes
No
Are you prepared for the
responsibility of adopting another member into your family for the
next 7 to 10 years?
Yes
No
Are the individuals with
whom you live willing and prepared to allow you full charge of the
service dog?
Yes No
Section VI: You and Your Environment
How do you deal with your anger toward personal friends?
Towards authority figures?
Towards animals?
How do you respond to frustration towards people?
Do you consider yourself self-motivated or do you rely more on
encouragement and emotional support of others? Please explain:
Do you plan to take the service dog to work, shopping malls, grocery
stores, and other places, after you complete training? Please explain:
Section VII: Medications
Please list all medications
you are currently taking, the dosage (e.g. 25 mg. 2 times per day),
and their purpose. This MUST be a complete list. If you need more
room, please use additional paper.
Name
Dosage
Purpose:
Section VIII: Funding
CCA/AD relies solely on
fund-raising to acquire the $10,000 necessary to train each Service
Dog and recipient. Recipients are not required, but invited to assist
in fund-raising and promotion. Do you plan to pursue financial
assistance through any organization? If yes, please explain:
Section IX: Description of Request
Please explain why you would like to have a Service Dog:
California Canine Academy Assistance Dogs