Answer these questions, describing your situation, to get started.

You may request a version of this application that can be filled out and returned by e-mail. heritageservicedogs@gmail.com

This application can be printed off and mailed to
PO Box 762, Milton Freewater, OR 97862


Name____________________________ Birthdate__________

Sex___ Height____ Weight_____ Grade Completed in School___

Address____________________________________________

__________________________________________________

Phone____________________ e-mail_____________________

Needs Assessment

Type of disability:  Must check one to meet ADA guidelines.

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       , hearing-alert       ,    open doors       , rescue work       , retrieval       ,       sight       , stability to stand       , stability to walk       ,
Other tasks:                                                                                         ,
medical treatment/safety alert       ,  allergens       , anaphylaxis       , anxiety       , asthma       , blood sugar       , cardiac       ,  autism       ,
hypertension       , fatigue       , carry medications and instructions       , concentration       , insomnia       , ptsd       , heart palpitations       , respiratory dysfunction       , seizures       , shortness of breath       , parkinsons        , OCD       , ADHD       , ADD       , migraines       ,
back pain       , other severe pain                                                          ,
Other conditions:                                                                                   ,
prevention and interruption of impulsive, repetitive behaviors       ,
specific behaviors:                                                                               ,

Do I have a Doctor's diagnosis for my condition(s)?____________

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_______________________________________

How will I take care of a dog's daily needs?

Food______________________________________________

Exercise___________________________________________

Toileting___________________________________________

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?_______________

Who?_____________________________________________

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 utilizing this service, 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 program involves a live animal. Animals by nature can be unpredictable. 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 agree to abide by all the rules and regulations promulgated by the ADA and, Heritage Service Dogs. The articles on this website contain the opinions of the author and are offered for educational purposes only. Nothing on this site is intended as legal, medical or veterinary advice or to provide answers to a specific situation. Heritage Service Dogs is not engaged in the practice of law or medicine and cannot render those professional services or advice. Always consult a competent professional.

All rights reserved. All information on this site has been created for the specific use of Heritage Service Dogs and itsí clients and shall not be shared or used for any other purpose without prior written authorization from HSD. None of the content shall be copied or distributed by any means mechanical or electronic without express prior written authorization from HSD. All logo's content and format are protected by copyright law. To the best of our knowledge all items are original or from public domain. If you have any questions regarding this site or itsí content please contact HSD.

By my signature, I declare as an authorized authority, that this filing has been examined by me and is, to the best of my knowledge and belief, true, correct, and complete. Making false statements in this document is against the law and may be penalized. 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: Each Applicant and their legal representative 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

___________________________________Date____________

Signature of Parent or Guardian

___________________________________________________

R
elationship


Signature____________________________Date____________
If you are under 18 years of age, you will need a signature from your parent or guardian

___________________________________Date____________
Signature of Parent, Guardian or Legal Representative

___________________________________________________

Relationship
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.

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