Facility Dog Application (To be completed by person to handle & house facility dog) of application / / Name of applicant Street address Mailing address (if different than above) City State ZIP code Email address Home phone ( ) - Cell phone ( ) - Other phone ( ) - Alternative contact in case we can t reach you ( ) - Relationship to the alternative contact listed Gender: Male Female of Birth / / Age Have you applied to any other program for a facility dog? Yes No Do you consider yourself: (Circle one) Active Very Active Inactive What are your hobbies/regular activities? Are there specific places you visit regularly that a dog should be comfortable with such as physical therapy, public transportation, school/university etc? Are there medical considerations that may affect how you interact/handle a dog? Yes No P a g e 1
Do you have any disabilities: (Please check all that apply) Speech Hearing Vision Impaired reaction speeds Learning (please indicate type) Mobility Information: (Please check all the apply) Walk Normally Walk slowly but steadily Walk Unsteadily Non-Ambulatory Wheelchair-Manual Wheelchair Power Crutches 1or2 Cane Walker Braces Right Handed Left Handed Do you have limits in arm or hand movement, please explain: Family/Living Situation What is your marital status? Single, never married Married Divorced Widowed Separated Have you ever been convicted of a felony? Yes No Are there currently any felony charges pending against you? Yes No Have you ever been invested for animal neglect or cruelty? Yes No If yes, explain: In what type of residence do you reside? Private home Apartment Dormitory Assisted Living Facility Group Home Mobile Home Other How long have you lived at your current residence? Do you plan to move in the next two years? Yes No If yes, please explain Do you live in a single story home? Yes No If no, is there an elevator/stair lift available for your use? Yes No Are there stairs going up to your residence? Yes No If yes, is there a ramp available for you? Yes No Do you have a fenced yard available for your use? Yes No Is there a pool in your yard? Yes No If yes, is the pool area fenced? Yes No P a g e 2
Do you live: Alone With spouse or significant other With parents With minor child(ren) Please list age(s) With grown child(ren) Please list age(s) With roommate(s) How many roommates share your home: Please list their age(s) and gender(s) M/F Age M/F Age M/F Age M/F Age With live-in caregiver Other (please specify) How many people live with you in your home Are there any other family members in your home with disabilities? Yes No Not applicable If yes, please specify Are you or anyone you live with allergic to dogs? Yes No If yes, explain Is anyone you live with afraid of or fear dogs? Yes No If yes, explain How many other pets do you live with Do you own these pets? Yes No Please indicate the type, age, and whether they live inside or outside for each pet: Have you ever owned a dog? Yes No What is your prior experience with dogs and their care? Are there traits that you like or dislike in dogs or certain type/breed of dogs? Facility dogs need daily care such as feeding, exercise, attention, and care. Please check all that you are willing to commit to and can provide: Veterinary Care Heartworm medicine Flea care Recommended Food Weekly grooming Ongoing training Emergency Care Exercise Ensure your dog behaves appropriately in public Being the person responsible for your dogs care and well being P a g e 3
Employment What is your current employment status? Employed, full time Employed, part time Unemployed Student (please specify level) How many months and/or years have you been with this employer? What is your job title/occupation? Are you exposed to paints, fumes or chemicals or other potential toxins on a regular basis while you work? Yes No If yes, please explain Is your work location stationary (office/desk job, classroom)? Yes No When not working with the facility dog, do you have a space at work where it can rest? Yes No Please explain Are you exposed to any loud noises on a regular basis on your job? Yes No If yes, please explain Acknowledgement and Signature I certify that all of the answers I have provided on this application are up to date, accurate and true to the best of my knowledge. I understand that completing an application does not guarantee acceptance as a Deafinitely Dogs! client, or placement of a service dog from Deafinitely Dogs! I understand and have included a $35.00 non-refundable application fee with my completed application. Signature of applicant Printed name of above P a g e 4
(Facility Information to be completed by facility supervisor) Name of facility Street address Mailing address (if different than above) City State ZIP code Email address Office phone ( ) - Cell phone ( ) - Other phone ( ) - Please describe your facility and the client population you serve: Explain the role or ways the proposed Handler for the facility dog is directly involved with your clients: Describe how you feel a facility dog will benefit your facility and the reasons for wanting one: P a g e 5
Describe a typical day at work for the proposed handler: Facility dogs need daily care such as feeding, exercise, attention, and care. Please check all that you are willing to commit to and can provide: Veterinary Care Heartworm medicine Flea care Recommended Food Weekly grooming Ongoing training Emergency Care Exercise Ensure your dog behaves appropriately in public Being the person responsible for your dog s care and well being We will arrange for a back-up handler to assist with the Facility Dog s care and handling in the event that the primary handler becomes unavailable: Yes No Name of backup facilitator I feel this facility would be able to use a Facility Dog from Deafinitley Dogs! effectively to accomplish work/client related goals. Supervisor Name (Printed) Supervisor Signature Supervisor Title P a g e 6
General Release of Liability Statement I hereby release any liability(ies) or claim(s) in participating in any activities or services sponsored by Deafinitely Dogs!, Inc. organization. I acknowledge that I assume the risks and responsibilities in such participation and hold Deafinitely Dogs!, Inc. harmless for any injuries or liabilities incurred or sustained in my participation. It is understood and agreed that, by acknowledging and signing this release, I irrevocably, unconditionally and completely releases and forever discharges Deafinitely Dogs!, Inc., and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents from any and all losses, demands, damages, obligations, liabilities, actions, causes of action, debts, suits, judgments and all claims of any kind or nature whether known or unknown, fixed or contingent, arising directly or indirectly from, as a result of or in connection with, or otherwise relating in any manner to any claims of liability, that were alleged, or could have been alleged, against Deafinitely Dogs!, Inc., and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents, that may in the future develop from or be caused directly or indirectly from any actions causing such liabilities. I acknowledge that I provide this release voluntarily and knowingly. Signature of Facility Supervisor Signature of Proposed Handler P a g e 7
Photo Release I understand and agree that the Deafinitely Dogs!, Inc. will be photographing applicants, student, students with dogs, graduates and volunteers during training and events for the purposes of providing community education and/ or promoting the program. This may include still photos and/or videography. I understand that there may occasionally be TV stations and/or news reporters who may be present at classes and events to take footage and/ or photos of students and dogs for training and/ or publicity purposes. I hereby grant Deafinitely Dogs!, Inc permission to use these photos or footage, and grant permission to newspapers or TV stations to use these photos or footage for training and/ or publicity purposes. I understand and agree that all photos taken by Deafinitely Dogs!, Inc. during the training are the exclusive property of Deafinitely Dogs!, Inc., and Deafinitely Dogs!, Inc. reserves the rights to all such photos or videography. Signature of applicant Signature of Proposed Handler P a g e 8
Fund Raising Facility Dogs are placed for free with each facility. There is a minimum donation of $7500. Deafinitely Dogs! is a 501 (c) (3) and donations are tax deductible. Please list at three clubs, churches, organizations, etc.. that you believe you would be willing to sponsor the cost (in total or in part) of a facility dog for your organization. 1. Organization Name Contacts First & Last Name Address Phone ( ) - Email 2. Organization Name Contacts First & Last Name Address Phone ( ) - Email 3. Organization Name Contacts First & Last Name Address Phone ( ) - Email Please note: If approved for a Facility Dog from Deafinitely Dogs! you will be given fundraising information and instructions. P a g e 9
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