Application for Service Dog

Eligibility Requirements for a Service Dog:

Must be a military veteran, first responder or applying for the Owner Trainer Academy with your own dog.
Have a physical disability, debilitating chronic illness, neurological disorder, or psychiatric disorder that is medically substantiated by a physician or therapist.
Be physically and cognitively capable of participating in the training process, up to one hour per day of training.
Be able to independently command and handle their Service Dog.
Be able to meet the emotional, physical and financial needs of the Service Dog.
Be in a stable home environment.
Have a realistic plan of use for an Service Dog.

PLEASE NOTE:

Our first priority is providing program service dogs to military members, military veterans, first responders, and current clients (successor dogs). We offer an owner-trainer academy for local disabled individuals wishing to train their own dogs to assist them with their disability.

We currently have a 3 – 5 year waiting list for our service dogs. We encourage applicants to research alternative training programs in addition to Custom Canines. Home interviews will be done as dogs become available for potential placements.

Placements are not on a "first-come, first-served" basis, but are based on a careful match of skills, needs, and personalities of dogs and people alike.

Custom Canines requires a $75 application donation. This donation is tax-deductible and you will be redirected to a PayPal payment page after completing this application. This $75 application fee is non-refundable.

This is a detailed application and we highly recommend periodically saving your application by using the "Save my progress and resume later" checkbox and form at the top of the page. You can continue to save and resume/edit your form until it has been submitted. Once submitted, you will no longer be able to access the form.

You will need to provide a Medical History form to you Primary Care Physician and have them return it directly to Custom Canines. You will receive the Medical History form in the confirmation email you receive after completing this application.

You will be required to upload a photo of yourself near the end of this application.

Required fields will have a red asterisk *.

If you have any questions regarding which type of Service Dog to apply for or about completing the application, please call 844-888-8850 or email to info@customcanines.org

If you have your own dog that you would like to train as your service dog, please select the OWNER TRAINER ACADEMY as the option for the type of dog you are applying for. Thank you very much!

What type of Service Dog are you applying for?

Are you completing this application for a minor child whom is disabled?

Are/were you in the military?

Is your disability military related?

Page 2

Applicant General Information

Please fill these General Information fields for the minor.

First Name

Middle Name

Last Name

Birthdate (mm/dd/yyyy)

Gender

Height (#' ##")

Enter height as feet and inches. Ex: 5' 8"

Weight in pounds

Enter weight as pounds. Example: 155

Parent/Legal Guardian:

First Name

Middle Name

Last Name

Contact Information

Preferred Communication Type

Mailing Street

Mailing City

Mailing State/Province

Mailing Zip/Postal Code

Preferred Email

Personal Email

Work Email

Alternate Email

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Fax

Emergency Contact

Nearest Relative Name

Relationship

Is Emergency Contact Address same as Above?

YesNo

Address

City

State

Zip

Address

City

State

Zip

Primary Phone

Alternate Phone

Page 3

Military Information

Branch of Military Service

Military Rank

Submit DD214

Copy of DD214

If you do not have a copy of your DD214 go to: https://www.archives.gov/veterans/military-service-records. Or visit your local VA office and they will request it for you

Dog Information

Do you believe you are capable of training your own Service Dog under the guidance of a Custom Canines Professional instructor?

Please tell us the status of the dog you hope to train

What is the breed of your dog?

Dog's Name

Dog's Birth Date

Dog's Microchip #

Dog's Gender

Spayed/Neutered Date

Weight (required if your dog will be pulling a wheelchair or providing mobility support)

Height at Withers (required if your dog will be pulling a wheelchair or providing mobility support)

Dog's current veterinary clinic

Please explain why you feel that this breed of dog you have will be best suited as your Personal Service Dog?

What type of Service Dog are you looking for and types of tasks your dog will perform for you?

Hold down the Control Key to make multiple selections.

Please explain other type:

Is the minor planning on having the service dog accompany them to school?

Do they have an IEP?

Will you be taking your Service Dog to work outside your home?

What is your experience with training dogs/have you ever trained a dog before?

Disability Information

Define your specific need for a Service Dog (please be as specific as you can):

Please describe the tasks you are expecting your dog to perform to help your disability:

Primary Disability

How Long?

Secondary Disability

How Long?

Please tell us about your disability. This may include Progression:

Effects on Communication

Range of motion, strength, endurance, balance

Attendant care, personal assistance

Anything else you think will help us understand this disability?

Is he/she aggressive towards you or others?

Any aggression towards animals?

Military Date of Disability (mm/dd/yyyy)

Active Duty Injury?

Define Disability (please be as specific as you can)

Cause of Disability (please be as specific as you can)

Equipment Required

Please select the equipment you use

Hold down the Control Key to make multiple selections.

Other equipment used

Strength Assessment

Rate your physical strength on a scale of 1 to 10

(1 = Least and 10 = Most)

Strength Right Hand

Strength Left Hand

Strength Right Arm

Strength Left Arm

Strength Right Leg

Strength Left Leg

Strength Upper Body

Page 4

Are you

Employeda VolunteerNeither

Employment Information

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Supervisor

Employer Supervisor Phone

Employment Type

Employment Hours Weekly

How long have you been employed here?

Volunteer

Volunteer Organization Name

Volunteer Address

Volunteer City

Volunteer State

Volunteer Zip

Volunteer Supervisor

Volunteer Supervisor Phone

Additional Information

Source(s) of Income

Hold down the Control Key to make multiple selections.

Describe Other Income

Describe your work/volunteer activities in helping us understand what a service dog would encounter in this environment:

Page 5

References

Please fill in personal references. (NOTE: One reference must be a non-relative).

You must provide the names and contact information for two individuals who have agreed to provide support to you and your dog. These individuals must agree to provide an immediate and temporary home for the dog should an emergency arise.

Reference 1

First Name

Middle Name

Last Name

Address

City

State

Zip

Preferred Email

Personal Email

Work Email

How long have you known them? Years:

Valid entry 0 - 99

Months

Valid entry 0 - 11

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Relationship to applicant

Best way to contact

Best time to contact them?

Reference 2

First Name

Middle Name

Last Name

Address

City

State

Zip

Preferred Email

Personal Email

Work Email

Preferred Phone

Home Phone

Work Phone

Mobile Phone

How long have you known them? Years:

Valid Entry 0 - 99

Months

Valid Entry 0 -11

Relationship to applicant

Best way to contact

Best time to contact them?

Page 6

Household Information

Names and ages of people living in the home and/or taking care of the applicant on a regular basis. Use the "Add another household member" link below to add multiple household members.

Name

Birth Month/Year

Enter as MM/YYYY

Relationship to applicant

Have all members of the household agreed to have a service dog in the home?

Do all members of the household agree to help care for the service dog if required?

Who will be the primary person responsible for your Service dog?

Are you willing to take responsibility for a dog for the next 10 more years?

How much do you estimate it will cost to care for a dog for one year (food, vet bills, etc.)?

Does anyone in your household have allergies to animals?

Household Allergy Explain

Have you ever, and under what circumstances, brought an animal to a shelter or rescue or humane society?

Do you own or rent?

What type of housing do you live in?

How long have you lived at this address?

Landlord Name

Does your current rental allow pets? Under ADA Law a service dog must be permitted, however, this question tells us something about how this might be received, and we can help you with this process of educating the landlord and neighbors.

Do you anticipate a move within the next few years?

Do you have a completely fenced yard?

Type of fence

Fence Height (#' ##")

Enter height as feet and inches. Ex: 3' 8"

If no, or it is not completely fenced, how you will contain a service dog on your property?

Is there a pool?

Is the pool secured?

Have you checked your yard for dangerous objects or plants?

Yard Checked Results

Are there distractions outside your yard?

Hold down the Control Key to make multiple selections.

Describe other distractions

Page 7

Current Pets

Do you CURRENTLY own any other pets?

List them here and use the "Add another pet" link in the bottom right of this section to add each pet.

Pet Name

Species Breed

Pet Age

Gender

Neutered/Spayed or Intact?

How long have you had this pet?

Dominate/Submissive? Gets along fine with other dogs, children, cats, etc? Any behavior issues?

Where is this pet kept during the day and night?

Pet History

Have you had any animals you once owned but no longer do?

Add all animals (birds, cats, dogs, etc.) you once owned but no longer own, since you turned 18. Use the "Add a previous pet" link in the bottom right of this section to add each pet.

Pet Name

Species Breed

Age when you got it

Gender

Neutered/Spayed or Intact?

How long did you have the pet?

Where was this pet kept during the day and night?

Reason you no longer have it; if pet is deceased, list age of pet when it died and cause of death

Page 8

Veterinary References

Please list any veterinary reference(s). Please include current & previously used veterinarians used for your current pets. If you currently do not have a vet, please list the vet you plan to use for your new CCSDA. You must call your veterinarian and inform them that we will be calling to check on your pet's records.

You should do this soon after receiving confirmation from us that we are processing your application, otherwise it may result in a delay in processing your application. You have to have your vet reference processed in order to be eligible to work with a Custom Canines Service Dog candidate. Please inform your vet that you are authorizing the release of these records/information to the CCSDA representative who calls them. Thank you.

Vet Name

Vet Clinic Name

Vet Address

Vet City

Vet State

Vet Email

Vet Phone

Vet Status

Service Dog Care

Are you able to meet the needs of a CCSDA in terms of regular veterinary care, heart worm and external parasite prevention, feeding high quality dog food, treats, grooming, exercise, play, training, and yard clean up?

Will you need assistance, either physically or financially, and if so, who will provide this assistance?

How do you foresee giving a service dog exercise and play?

Page 9

Personal Interests, Skills & Activities

Please describe your basic daily schedule, activities, environments visited, how you spend your time in a typical week: (M-F may be the same, Sat and Sunday different from weekdays).

Please add any other activities or interests, travel, hobbies, recreational activities you enjoy.

Do you foresee having your service dog accompany you in your daily activities and special events? To what extent?

Please tell us in your own words

Why do you want a Service Dog? What changes/benefits in your life do you foresee a service dog bringing to you?

Describe your ideal dog (i.e. temperament, skills, activity level, size, male or female, breed preference?

Tell us how you feel about learning about service dog handling skills, attending training classes, working with volunteers during placement and transitioning, giving the time and energy needed to create and foster a working bond with a new dog?

Tell us any other information about yourself and your application for a CCSDA that you would like to included:

Page 10

Photo

Please upload a picture of the applicant

CCSDA Application and Placement Policies APPLICANT AGREEMENT

• I certify that the information I provided in this application is true and correct.

• I understand that to complete the processing of this application, a visit to my home will need to be scheduled by a representative of the organization. All members and pets living in the household must be present at the time of the visit. A visit to your workplace, if you are applying for a full service dog, may also be conducted.

• I authorize Custom Canine Service Dog Academy to contact any and all references to verify the information that I have provided.

• I acknowledge that any misrepresentation or falsehoods will disqualify our application. I also acknowledge that any misrepresentation/falsehood may result in termination of the placement.

• I grant permission to Custom Canines Service Dog Academy, Inc. to take photographs, images, and audio or visual recordings of me, including my image or likeness, and I consent to the use of those photographs, images and recordings for the purposes of publication or any other lawful use in conjunction with Custom Canines Service Dog Academy, Inc.'s activities in any manner and medium, including, without limitation, in print or on the Internet. I acknowledge that Custom Canines Service Dog Academy, Inc. shall own those photographs, images, and other recordings, and any other intellectual property. I further understand and agree that I shall receive no payment or royalty as a result of the use or publication by Custom Canines Service Dog Academy, Inc. (or its designee) of any photographs, images, or recordings, nor shall I be entitled to receive notices of such use or publication.

• CCSDA reserves the right to refuse or deny any application.

• CCSDA will keep your application on file for one year. After that you will be required to fill out a new application.

• Applicants must live within the CCSDA service area.

• CCSDA may require further medical information not included on this initial application in order to process your application for a CCSDA Service Dog.

• All applicant information will be kept confidential and the property of CCSDA.

• Acceptance of this application does not guarantee a placement with CCSDA, or a placement within any given time frame. Placements are not on a “first come, first served” basis, but are based on a careful match of skills, needs, and personalities of dogs and people alike.

• Applicant acceptance is decided without regard to race, religion, gender, or sexual orientation.

• I agree that I will attempt to help CCSDA in other ways as I am willing and able: with potential recipients or volunteer trainers in the training room, in fund raising efforts, in communication with the public or other clients and volunteers, etc.

• I understand that any financial gift I may choose to donate to CCSDA is fully tax deductible.

• I understand that a CCSDA dog is a helper to me but not responsible for my health or safety either by protection in home or public, alerting to dangers, or alerting others that I may need help, or delivering medications to me.

• I understand that I am responsible for the health and well-being of the service dog by providing appropriate veterinary care, grooming, high quality food, exercise, licensing, and safety.

• I understand that all service dogs in public must be on leash, unless in a dog- designated and secure off-leash area.

• I agree to have my CCSDA service dog wear his/her vest in public and carry the ID card with me for purposes of identification as a CCSDA service dog.

• I agree that any cost for my own travel or my own accommodations or meals during the placement process is my own financial responsibility and not covered by CCSDA.

• I understand that my own pets must meet the behavioral and health standards of CCSDA in order for a placement to occur.

• I agree not to add a new pet into my home in the first two years of placement.

• I agree to participate in Public Access testing on a periodic basis as determined by CCSDA.

• I agree to fully participate in home visits, interviews and training sessions as directed by CCSDA during the application/placement process.

• I understand that at any time during the placement process; if the CCSDA staff determines I am unable to meet the standards to manage care and safety for the service dog, CCSDA reserves the right terminate placement activities.

• The CCSDA Board of Directors reserves the right to change these policies at any time.

• I agree that this dog Is the property of CCSDA and I/we will not GIVE, SELL, TRADE, ABANDON, SURRENDER OR OTHERWISE TRANSFER ANY TYPE OF OWNERSHIP/GUARDIANSHIP, PHYSICAL POSSESSION OR RESPONSIBILITY for this dog to any other persons/Individuals or organization (shelter/rescue/vet or otherwise) for any reason whatsoever.

• If I can no longer keep the dog I agree to notify Custom Canines Service Dog Academy. CCSDA will determine the best possible outcome for the service dog, taking into account the circumstances that have caused this inability to keep the dog with the client. In the case of death or changed medical conditions of the client, it may be determined, if the family wishes, that they retain the dog.

• I agree that CCSDA will be held completely harmless for any medical problems, behavioral problems or any incidents that may occur after placement of the CCSDA service dog.

• The recipient agrees to follow support services recommendations or requirements after placement for maintaining training, behavior management, veterinary care, health, care, grooming, Public Access testing for recertification.

• I hereby release Custom Canines Service Dog Academy, Inc. and its officers, directors, employees, agents, and volunteers from any liability for any injury to my property or person as a result of or following any accident or occurrences on or about the premises of the School or any facility controlled by Custom Canines Service Dog Academy, Inc., or from any of its operations while I am a client of the School.

• I understand and acknowledge that the application fee, Owner Training Academy tuition, if applicable, and any subsequent donations given to Custom Canines Service Dog Academy, Inc. are non-refundable.

Applicant Signature

If the applicant is a minor, under guardianship, or a ward of the court, the parent or guardian is required by law to sign this form.

Applicant's Signature

Please enter your full name

Current Date

Signature of Person assisting with this application

Please enter your full name

Paypal_Hidden_Fields