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Service Dog Application

Instructions:
The Service Dog needs to be the only dog in the home. You must be at least 18 years old to apply. We prefer dealing directly with the person applying for the Service Dog, unless you are applying on behalf of a child.


Submitting your application:
Fill out this application and e-mail to Polite Paws by pressing the Submit button at the end of this page. If you prefer, you may print this form from your browser and mail it to Polite Paws, Inc. 21-B Scott Way Bluffton, SC 29910

Application Form: Service Dog

Name:
Address:
City:
State:
Zip:
E-Mail Address:
Home phone:
Work phone:

Are you applying for a service dog for yourself or for a child under the age of 18 years old living in your home?
applying for myself child under 18

Your age:
Spouse's Age:
Employer:
Spouse's Employer:

Describe your work schedule:

Please give the name of a friend or relative we can call if we can't reach you:

Name:
Relationship:
Phone:
Work phone:

Are you or anyone living with you allergic to dogs?
Yes  No


If yes, who is allergic and to what extent?


Describe your disability:

Number of years disabled:
Cause of disability:

Marital status:
Single Married Divorced Separated Widowed


How many people live with you?

Please list the people who live with you -
Name Age Relationship:

Current living arrangement (check all that apply):

Live independently In a house
Live with parents In an apartment
Live with attendant In trailer home
Others In group housing

If you use attendant(s), who pays his/her wages?

What forms of transportation do you use?

Do you use a wheelchair?

Yes, manual Yes, power No

Please describe other specialized equipment you use (mouthstick, van lift, special car keys, etc.):

Your Height: ft. in.
Your Weight: lbs.

Physical challenges:

Mobility Physical strength
Endurance Reaction speed
Heat sensitivity Speech difficulty
Pain sensitivity  

Other:

Activity level: Low Moderate High

Please list any additional health problems (e.g. diabetes, epilepsy, cerebral palsy, etc.):

Describe your leisure activities (TV, visit friends, team sports, shop, travel, computers, eat out, etc.):

If you are a student:

where do you attend school?
Full time or Part-Time?
Anticipated date of graduation?

Have you ever had a dog? Yes No
Please describe:


Do you have a dog now? Yes No

If yes, what kind/ how old?


Please list any other pets you also currently own:


Do you have the financial resources (at least $1500/year for 7-10 years) to provide indoor living accommodations, quality food, routine veterinary/dental care, emergency care, grooming, daily exercise, adaptive equipment replacement & repair and boarding fees- when necessary- for a service dog?
Yes No

Are you willing and financially able to participate in an initial two week training period with the trainer in Bluffton, SC. and then follow-up training 1-2 times a month for six months (also in Bluffton)?
Yes No

What tasks would you like a service dog to be able to do for you?

Will the dog travel with you?
All the time Sometimes Never


Do you plan to take the dog to your workplace?
Yes No


Do you consider yourself knowledgeable about dogs?
Yes No


Do you have strong feelings about what traits you like and dislike in dogs?
Yes No


If so, what are they?


What lifestyle changes do you anticipate making in order to meet your service dog's ongoing physical and psychological needs?

Are the individuals with whom you live willing and prepared to allow you full charge of the service dog?
Yes No Not applicable


Do you plan to take the service dog to work, shopping malls, grocery stores, and other places, after you complete training? Please explain:



Please list all medications you are currently taking.
Name Dosage Purpose:

Please explain why you would like to have a Service Dog: