Application Process

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. heritageservicedogs@gmail.com

Name -             Birthdate -           Age -

Sex -         Height -         Weight -     Grade completed in school -

Address -                City -         State -       Zip -

Home Phone -          Cell Phone -

e-mail -

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___
Other tasks:

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___
Other conditions:
prevention and interruption of impulsive, repetitive behaviors___________
specific 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?

Why?

Have you had a Service Dog before? yes - no -

When? -

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? -

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? yes -     no -

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? -


LIABILITY RELEASE
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

Relationship -