Exceptional Partner Service Dog Application
What type of service dog would meet your needs?
Do you want to train your own dog as a service animal?
Contact Information
First Name
Your answer
Middle Initial
Your answer
Last Name
Your answer
Name of Parent or Guardian (If applicant is a minor)
Your answer
Age of Applicant
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Work Phone
Your answer
Occupation or Former Occupation
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Emergency Contact Relationship
Your answer
Environmental Information
Have you ever served in the military?
Are you a student?
Have you discussed this application with your doctor and is s/he in support of a service dog?
Have you discussed this with your family or caregivers and are they in support of a service dog?
Is anyone in your house allergic to dogs?
Do you have other dogs in the house?
If you have other dogs are they spayed or neutered?
If you have other dogs are they friendly?
Required
Do you have other pets in the house? Please list
Your answer
Do you have a good friend or family support system?
Are both parents willing to accept a service dog in their child’s life?
Will the dog be going to school with the child?
Service Dog Information
Please give us a brief history of your disability. (Please do not include abbreviations or initials when discussing your disability.)
Your answer
Are you able to travel to our facility for 2 weeks of handler training?
Please explain briefly how your disability affects your life and current level of independence
Your answer
What specific needs or services do you feel an Assistance Dog can provide for you?
Your answer
Will you have time to spend with the dog?
Will you be able to exercise and potty the dog multiple times per day?
Will you be able to take the dog to the veterinarian?
Will you be able to clean up after the dog goes to the bathroom?
Will you be able to groom the dog?
Lifestyle
Have you ever had a dog before?
Will your service dog accompany you to work or school?
Will your service dog accompany you on vacations?
How many hours a day will your service dog be alone?
Your answer
Do you live in a house or apartment?
Your answer
Do you own or rent?
Your answer
Do you have a yard?
What are your hobbies / interests?
Your answer
Do you have a gun in your home?
If so, will you be taking your dog to the shooting range?
Do you or anyone in your house smoke?
What types of transportation do you use?
Required
Guidelines
If I get approved to receive a service dog from The Exceptional Partner, I will be required to travel to Newtown,CT for a minimum two weeks of training.
Required
I understand that I must have a medical diagnosis (from a licensed & qualified medical professional) that warrants placement of a service dog. If applying for a psychiatric service dog, I must have a diagnosis from a qualified & licensed mental health professional & be actively engaged in therapy for a minimum of one year.
Required
I understand that the estimated yearly cost of caring for a service dog is roughly $2,500 and I understand that I am responsible for those expenses.
Required
I understand that if I am approved for a service dog from The Exceptional Partner, I will be subject to a criminal background check prior to the dog being placed in my care.
Required
I understand that I will be asked to support The Exceptional Partner through fundraising before a dog can be placed with me. The Exceptional Partner will help me by providing support, ideas, and all marketing materials that fit my ability. The Exceptional Partner can not survive without my support as well as my families support. I will take pride in supporting them as they prepare dogs for a life of service work. While everyone has different abilities, I am capable of contributing time and energy to an organization that means so much to me.
Required
I understand that applying for a service dog does not guarantee the placement of a service dog.
Required
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