Name: ____________________________________________
Date: _______________________
Are you completing this application on behalf of
someone else? [ ] yes
[ ] no
If yes, please state your relation to the person who
desires the companion dog: ____________________
Address: _________________________________________
Phone:
(W) __________________
_________________________________________
(H) __________________
County_________________
Birthdate: _________________________________
SS# ___________________________
E-Mail: _____________________________ Are
you under the age of 18? [ ]
yes [ ] no
Do you have any disability that would impair your
ability to take care of the dog? [
] yes [ ]
no
If you have a disability that deteriorates your
health, who will take responsibility for the dog’s care and are they
willing to do so for the lifetime of the dog?
___________________________________________________________________________________________
Do you have a caregiver?
[ ] yes [
] no
Are there any other animals in your home?
[ ] yes [
] no
If yes, please list type, breed and ages:
______________________________________________________
_____________________________________________________________________________________
Can you be financially responsible for the lifetime
of this dog’s care? [ ]
yes [ ] no
Please list all the people residing in your home
and their ages: __________________________________
_____________________________________________________________________________________
Do you own or rent your home? [ ] own
[ ] rent If
renting, does the landlord allow pets? [ ] yes
[ ] no
Include a copy of your rental agreement showing
that the landlord allows pets or letter from the landlord.
Have
you ever owned a dog? [ ]
yes [ ] no
If yes when: ________________________________________
Did you train it yourself or other? __________
In order to select an appropriate canine companion
for you we ask that you complete the following questions with as much
information as you feel is necessary for us to get to know you.
Please describe your home/family and general
schedule (i.e. how long will the dog be left home alone):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have a fenced in yard? [
] yes [ ]
no
How
high is the fence? ______
What type? [ ]
chainlink [ ] wood
[ ] other _____________________
If no fenced yard, are you willing to always walk the dog on a leash at
least twice a day for at least 30 minutes?
[ ] yes
[ ] no
Approximately what percentage of the day are you
away from home? ________
Do you travel?
____________ Where
and how often? ______________________________________
Will you bring the dog with you when you travel? [
] yes [ ]
no
If not, where will you leave the dog?
________________________
How did you find out about
California
Canine
Academy
/ Assistance Dogs? _______________________
Please include a photo of applicant
Please have a local vet of your choice send us a
letter saying that they will be caring for the dog’s health and will
cooperate with
California
Canine
Academy
/ Assistance Dogs follow up when we ask for the dog’s records.
We will make arrangements to have the dog’s health history sent
to your vet. (This letter
does not need to be sent with the application but will be necessary
before proceeding after initial interview.)
Please Complete Essays on
a Separate Piece of Paper
Description
of Recipient Essay:
The purpose of this essay is to enable
California
Canine
Academy
/ Assistance Dogs to understand your physical traits, lifestyle,
disability, activities and personality.
Through a detailed description of yourself, your home, your
family and your activities, we can better establish the type of dog most
suited for you. Describe
your ideal companion dog. Please
be as precise and comprehensive as possible!
Please read the following paragraph carefully:
I understand the term “companion dog” refers to
a dog that has been trained in basic obedience skills and that while the
companion dog has learned “house manners”, he/she has not received
the more advanced training of a full service dog.
Unlike the full service do/recipient team, in accordance with the
Americans With Disabilities Act, the companion/recipient team does not
have public access rights. Under
no circumstances is the companion dog allowed to go into any public
facility where pets are not routinely allowed unless given special
permission. In no way is the
companion dog to be represented as a full service dog.
Please have all adults residing in household sign below to acknowledge
that each understands the term “companion dog”, and understands and
agrees to follow the public access guidelines as noted above.
Name
______________________________________
Date _____________________
Name
______________________________________
Date _____________________
Name
______________________________________
Date _____________________
Name
______________________________________
Date _____________________
