Assistance Dog Application Form

Name

Email

Phone

Address

Your age

Number of people and ages of people living with you

Is everyone in the house on board with you having a dog?

Your diagnosis (brief description)

Please detail how your disability impacts your day to day life

If you need a medical detection dog, how often do you have a medical event?

What physical limitations do you anticipate having when it comes to training a dog

What tasks do you need a dog to perform for you and how often?

Do you own your home or rent?

If you rent, what is your landlords policy on pets?

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?

Yes

No

If yes, please explain in more detail

Are there any other pets at your home address? If so, please tell us what they are and how many.

If you have other dogs, do they have any behavioural issues? What is their current level of training?

Have you ever rehomed a dog? If yes, please explain why

If you have to leave home, in case of an emergency or planned, where would your dog stay?

Do you require the use of any aids? (ie wheelchair, splints, helmets etc

Are you able to give the dog walks and exercise?

Yes

No

Do you have a safe, secure and enclosed garden area?

Yes

No

Can you travel to training sessions when required to do so? (training is located in Ewhurst, Surrey)

Yes

No

Can you fully commit to keeping up with the dogs training schedule at home?

Yes

No

At any stage throughout the day or night will the dog be left alone? (ie for work etc)

If your application is successful you understand that the dog will belong to Adolescent Dogs and in the event that you need to rehome, the dog will be returned to Adolescent Dogs for rehoming

Yes

No

If your application is successful you understand that you will be fully responsible for any vet treatment, food, flea and worming treatment.

Yes

No

Do you agree once the dog is working in public that it is your responsibility to purchase public liability insurance?

Yes

No

Do you agree and consent to Adolescent Dogs using photos of you and your dog for further fundraising efforts?

Yes

No

If you are unsuccessful with your application would you like to be considered at a later stage?

Yes

No

Upload your letters of diagnosis

The date the form was completed and sent to Adolescent Dogs

Agree to sign up to Lifetime assistance dog programme membership (£499)

Yes

No

Agree to make a donation to support the programme

Yes

No

By signing below, you understand that any dog that is gifted to you will remain the property of Adolescent Dogs. You understand that the dog will be gifted, along with 4 to 6 weeks of residential training to get them started on their training journey and ongoing one to one lessons.

You agree to sign up for lifetime membership to the online academy (£499) to help with funding for the project and agree to make a donation of your choice to help support our assistance dog programme and the high costs associated with providing full training for our gifted assistance dogs.

You understand that Adolescent Dogs cannot guarantee that your dog will remain a suitable candidate as an assistance dog or pass their access test as this largely depends on the experiences the dog has whilst living with you and your commitment to training.

Signature of Potential Pup Parent*

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