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Service Dog Granting Qualifications

ADASDF places a limited number of trained service dogs with those who qualify for a service dog at no charge for the dog to the applicant. You will have to have the financial ability to properly care for and provide for the dog. You will have to have the financial ability to come to our location in Wisconsin and stay for one week or more, depending on your needs, while you train with the dog. The application below is a preliminary application and there will be a more in-depth medical history required from your physician with letter of recommendation after reviewing the preliminary application.

 

We have a policy to not place one of our service dogs in a home that already has a dog/dogs in it.  There is the exception in the case were there is already a service dog in place and for health reasons is not able to work for you anymore.  We will consider placement in that home.

           

Person who is filling out this application:
Have you ever had the use of a service dog?

Personal Information
Title Legal Name
Address 1 Address 2
City State
Zip Country
Home Phone Cell Phone
Email Marital Status
Height Weight
DOB
Personal References
Name Address Phone Relationship to You
1
2
3
Vet reference of the vet that will
be your dog's primary veterinary
Nearest Relative to you - Name Address
Nearest Neighbor to you - Name Address
Education Annual Income
Profession/Occupation Work Phone
Does your employer know you
are applying for a service dog?
Will you be taking your service dog to work?
How does your employer feel about the
presence of a service dog at work?
Name of person who is your work supervisor
Do you have any type of criminal record?
If so, please describe.
Describe yourself
(hobbies, activities, clubs, and interests)
Describe your average daily routine

Health Information
Are you a disabled veteran who became disabled during time in the service?
Describe your disability and how you became disabled.
How does your disability affect your daily life?
Do you have multiple disabilities? If so, please list them and how they affect you.
Do you smoke?
Are you assisted by other persons?
Do you use any type of aids, such as wheelchair, walker, prosthesis, braces, other?
Do you have a service dog now or have you ever had a service dog?
List your Primary Care Physician and phone number.
Do you take medications? If so, how do they help or affect you?
Living Situation
Do you live alone? If no, please list whom you live with and their ages.
Is anyone you live with allergic to animals?
How do the people you live with feel about a service dog?
Do you live in an apartment or house?
Do you rent or own?
If renting, please list your landlord and phone number.
How long have you lived at your present address?
If less than 5 years, list previous also.
Do you have a fenced-in yard?
Where will the dog be able to relieve itself?
Do you have any other animals living with you? If so, what are they?

Task for Service Dog
How could a service dog benefit you and what are you expecting from a service dog?
What tasks could a service dog perform that would be of benefit to you and assist you?
What is your primary and/or secondary purpose for a service dog?