In Home Service/ Hearing/ Companion Dog. In Home Service/ Hearing/ Companion Dog Questionnaire

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1 In Home Service/ Hearing/ Companion Dog General Information An In Home service or hearing dog is a dog that is trained in specific service or hearing dog skills such that they can perform the skills in the home for a person with a disability. An In Home companion dog is a dog that is provided to a family that has a child with a specific need because of a disability. An In Home service, hearing, or companion dog may be right for you and/or your family if: o You have a disability and would benefit from some extra assistance in the home while others are gone, but typically have family or friends that accompany you when out. o You have a hearing impairment and manage just fine with hearing aids but don t want to wear them when you are home. o You have a child with a disability that would benefit from the calming presence of a dog and companionship. o You have a pre-teen or teen with a disability that would benefit from a task trained dog but is not yet ready for the responsibility of a public access dog. If you think an In Home service, hearing or companion dog might be right for your or a family member, please complete the In Home Service/ Hearing/ Companion Dog questionnaire below. Once we receive this form, we will contact your for a phone interview. In most cases we will have you come to Circle Tail for a visit so we can gather more information on you or your family members needs. In Home Service/ Hearing/ Companion Dog Questionnaire Use this form to request adoption of a Circle Tail In Home Service/Hearing/Companion dog for yourself or a family member. We are requesting this information to guide us in making the best match between you, your family and one of our dogs. Please complete all questions, read the "In Home Adoption Information and Agreement" that follows the questions and submit the form to Circle Tail. Please note, besides this application, we will have a phone conversation and an interview at Circle Tail for the potential recipient and family. Depending on the type of service/hearing/ companion dog needed, additional training may be required.

2 Date In Home Service/Hearing/Companion Dog for. (please check one) Self Family member Age of person needing In Home Dog: Age of person completing application, if not self Applicant Name Street Address City/State/Zip Code Home Phone Work Phone Cell Phone that you regularly check Describe Applicant s limitations in detail including verbal/ hearing/ mobility/ etc. List the activities you expect service/ helper dog to help applicant with. What are the 2 most important activities for which help is needed? Is there an outside caretaker involved with applicant s care? Gender Preference Male Female No Preference Size Preference Extra small (under lbs) Small (15 30 lbs) Large (60 90 Giant (90 lbs or lbs) more) Medium (30 60 lbs) No preference Age Preference Yes Between ages: No preference Breed Preference Indicate any breeds you do not prefer

3 What breed(s)/ type(s) of dogs have you had responsibility for as the primary caregiver, and how long did you have each of them? Pets you currently have at home Name Species/ Breed Age Gender Male/ Female Current Vaccines? Y or N Spayed/ Neutered? Y or N Where is pet kept during day? Veterinarian's Contact Information Name Street Address City/State/Zip Code Office Phone Number of people in household, including applicant List children (under 18years old) in household and age Do you live in a: Town City Suburb Rural Housing House Condominium Apartment Mobile Home Do you have a completely fenced yard? Yes* No * If yes, please complete information below Approximate area (sq ft) Height 4 feet high 6 feet high Other height (please specify) Where will your dog spend his/her time when you're not home? Inside (describe location) Outside (describe location and shelter) Other (please describe) Where will your dog spend his/her time when you're sleeping? Inside (describe location) Outside (describe location and shelter) Other (please describe)

4 Do you need a dog who is able to be alone 4 hours or less/ day 4 8 hours/ day 8 10 hours/day hours per day I have visitors over: All the time I installed a revolving door A lot Sometimes I have occasional friends and family over Rarely I don t even know if my doorbell works How outgoing and social do you want your dog to be with other people? s/he is a "social butterfly" they want to say hi to everyone s/he is outgoing they say hi to people but returns and lays by my side s/he is more reserved will go say hi to people if directed but content only with me doesn't matter Do you mind house training a dog? No Yes (understand any dog may have accident or two while adjusting to new environment) Are you comfortable doing training with your dog to improve manners such as jumping, stealing food, and pulling on the leash, etc.? Yes No Are you comfortable doing training with your dog to maintain/ improve obedience and advanced skills? Yes No How much training are you willing to do? Do not want to do training Willing to do some training Willing to do a lot of training Do you want a dog who likes to exercise: hardly at all "couch potato" moderately minute walk per day, playing fetch, etc. a lot, a running/hiking partner Other (please describe):

5 How will you provide DAILY exercise (at least one hour per day) for your dog? Please consider your living arrangements, physical condition, and seasonal weather conditions. How much do you expect to spend yearly for the care of your dog, including food, medical care, boarding, grooming, toys, heartworm, and flea control, etc.? $ per year Anything else you would like us to know? Are you able to travel to Circle Tail (north east side of Cincinnati) for an interview and/ or any training sessions that may be required prior to and following partnership with an In Home Service/Hearing/Companion dog? Y N Is it OK to conduct a scheduled home visit BEFORE adoption? Yes No Is it OK to conduct a scheduled home visit AFTER adoption place? Yes No

6 In Home Service/Hearing/Companion Dog Adoption Agreement I have read this form and by signing below, I understand and agree to the following: 1. To keep this dog in accordance with local regulations. I will have him/her licensed within 30 days and then yearly. 2. To provide this dog with proper shelter, adequate food and water, and medical care to maintain his/her health and well being. 3. To establish a schedule of preventative medicine with a veterinarian. 4. To obtain immediate veterinarian care if the dog becomes sick or injured. 5. To maintain the dog s obedience and assistance dog skills. Circle Tail welcomes any questions about the care of the dog, training or any behavioral issues that arise during the lifetime of the dog. 6. This dog will not be sold, traded or disposed of, and if I can no longer care for him/her, I will consult Circle Tail about alternative placement. 7. This dog will not be used for any experimental purposes. 8. A representative from Circle Tail may visit the dog at any time upon notice. If not satisfied with the dog s living conditions or appearance, the dog may be reclaimed by Circle Tail. 9. Within one month of the original adoption date, this dog may be returned to Circle Tail for any reason and the adoption fee will be refunded. 10. I will be personally responsible for the humane care of my in home service/hearing/companion dog and Circle Tail, Inc. will not be held liable if this animal causes injury to a human or other animal, or damage to property after the adoption. 11. Circle Tail, Inc. reserves the right to resume ownership of the animal if the above conditions are not met. There is additional training required for the in home service/hearing/companion dog team Yes If required, I agree to complete it at Circle Tail (or otherwise directed) within the month. Yes No To be completed by: Recipient Initials: No Dog s Name/ID# Name Street Address City, State, Zip Code Day Phone Cell Phone Address Evening Phone Signature and Date