There are many types and degrees of disability. Your situation is like no other. We do not train dogs for a specific disability, our goal is to help you through the process of training a dog for you, and your specific needs.
Heritage Service Dogs holds your personal information in strictest confidence. It will only be used to assist you through the process of acquiring, training, and working with your Service Dog.
2009-2021 HERITAGE SERVICE DOGS
STANDARD POODLE PUPPIES FOR SALE
STANDARD PARTI POODLE PUPPIES FOR SALE
SERVICE DOG TRAINING PROGRAM
FEDERAL ADA LAW
OREGON WASHINGTON IDAHO
Service Dog Application
The purpose of this application is to give me a better idea how I can assist you.
Copy and paste into an email, move the cursor down into the application to fill it out and e-mail it back to me. firstname.lastname@example.org
Name - Birthdate - Age -
Sex - Height - Weight - Grade completed in school -
Address - City - State - Zip -
Home Phone - Cell Phone -
What are my disabilities / limitations?
medical___, physical , sensory , psychiatric , intellectual , mental ,
Specific type of assistance needed / tasks to train for:
(The crime deterrent effects of an animals presence and the provision of emotional support, well-being, comfort, or companionship do not constitute work or tasks for the purposes of this definition.)
mobility: pull wheelchair balance body adjustments__ stability___ standing
stability to walk___ retrieval open doors visual aid___ hearing alert___
medical treatment/safety alert allergens anaphylaxis anxiety PTSD___
asthma blood sugar cardiac autism fatigue insomnia___
carry medications and instructions concentration heart palpitations back pain___ OCD ADD ADHD respiratory dysfunction seizures COPD___
shortness of breath parkinsons hypertension migraines other pain___
prevention and interruption of impulsive, repetitive behaviors___________
Do I have a Doctor's diagnosis for my condition(s)? yes - no -
My diagnosis is:
I use special equipment or devices? -
Special Activities, such as work or school -
Describe in what ways you think a Service Dog could assist you.
Physical Assistance -
Psychological Support -
Emotional Support -
Medical Alert -
Special Needs -
Would you prefer a male or female service dog?
Have you had a Service Dog before? yes - no -
What happened to them? -
What tasks did they perform for you? -
Did you serve in the military? -
Is your disability service related? -
How will I take care of a Service Dog's daily needs? -
Medical Care -
Training / Correction -
Where will my dog go for exercise and toileting -
What is my living situation?
Rural community - Suburb - City - Country property -
House - Apartment - Facility - Other -
Do I need someone to assist me with my care? yes - no -
Who else lives in the home with me? -
Ages of children living in the home? -
What other animals live with me? -
Who takes care of them? -
What pets have I had before? -
Who took care of them? -
What happened to pets I owned before? -
By making this application, I am intending to be legally bound hereby, I understand
and agree and do hereby release from liability and to indemnify and hold harmless
Heritage Service Dogs, and any of its employees or agents representing or related
to this Program. This release is for any and all liability for personal injuries (including
death) and property losses or damage occasioned by, or in connection with any
activities related to Heritage Service Dogs. I further agrees to abide by all the rules
and regulations promulgated by the ADA and, Heritage Service Dogs.
By typing my name in the electronic signature field, I am agreeing to conduct business electronically with Heritage Service Dogs. I understand that transactions and/or signature in records may not be denied legal effect solely because they are conducted, executed, or prepared in electronic form and that if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement. Please Note: Applicant must electronically sign this form.
Signature - Date -
If you are under 18 years of age, you will need a signature from your parent or guardian
Signature - Date -
Signature of Parent or Guardian