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Dogs 2 Vets Application
Please fill out this application in its entirety. Please note that whatever address you provide on this application will be
used to send packages to. Please make sure this address can accept packages and mail.
Today’s Date:
Name:
Date of Birth:
Personal Information
Middle
Gender
CURRENT MAILING ADDRESS
Current Address:
City:
Permanent Phone:
Best Method of Contact
State:
Cell Phone:
Email
Last
Status:
ZIP Code:
Email:
Phone
Mail
Active
Veteran
Cell Phone
PLEASE ANSWER THE FOLLOWING QUESTIONS
How long have you been at the current address?
Do you own or rent your home?
Household members w/ ages of minors and relationship
Own
Rent
Name, address, and phone number of employer or school.
How did you hear about our Dogs2Vets Programs?
I am interested in the following program:
General Training
Puppy Training
Emotional Support Animal
Service Animal
Dogs 2 Vets Application
Part 1 General Questions
Years of Service:
Branch of Service:
Date of Discharge:
PLEASE ANSWER THE FOLLOWING QUESTIONS
Live within 1.5 miles of Chittenango, NY?
Yes
No
N/A
Able to commit to 1.5 hrs training/week at our facility?
Yes
No
N/A
Willing to commit to at least 6 hrs/week training your dog at home?
Yes
No
N/A
Open to learning and using new training techniques?
Yes
No
N/A
Willing and able to commit to at least 6 months of training for emotional support and up to or over 1 year of
training for service dog?
No
Yes
N/A
Financially able to provide for your dog’s veterinary and basic care?
Yes
No
N/A
Transportation to the facility weekly and for emergency care for your dog?
Yes
No
N/A
Any other members of your household have a disability?
Yes
No
N/A
Able to have a dog in your home?
Yes
No
N/A
Do you have the ability to physically and cognitively train and care for your own dog?
Yes
No
N/A
List any other pets in the home?
Are these pets trained? What methods used?
Dogs 2 Vets Application
Part 2 Dog Information
Complete part 2 only if you have a dog you would like to use for the program.
PLEASE ANSWER THE FOLLOWING QUESTIONS
What breed is your dog?
Name of dog?
Where did you get your dog?
How long have you had your dog?
Age of your dog?
Is your dog is spayed or neutered?
How many owners has your dog had?
Yes
Does your dog chase cats or small animals?
No
No
Yes
Does your dog have a bite history? (Has your dog ever Is your dog good with other dogs (other than dogs
bitten anyone or injured another animal?)
living in your home)s
No
Yes
No
Yes
Is your dog up to date on exams,vaccines including
My dog is friendly with people
rabies.
No
Yes
Yes
Is your dog comfortable in a crate?
My dog is current on flea/tick preventative.
No
Yes
Yes
No
No
Is your dog primarily an indoor or outdoor dog?
What are your dogs fears?
What excites your dog?
In your family, who considers the dog theirs?
Describe your dogs personality
How do you correct your dog?
How do you exercise you dog?
Have you done any training with your dog? if so, what
can your dog do reliably?
Can your dog do these behaviors anywhere?
Is your dog over 1 year and under 6 years old
Yes
No
Yes
No
Have you owned any dogs/cats in the past? If so, please let breed, when owned and what happened to them
if they are no longer with you.
Is your dog a bully breed or bully breed mix? Bully breeds consist of but are not limited to Mastiff, Pit Bull,
Standffordshire Terrier, American Bulldog, Rottweiler, Doberman, etc.
No
Yes
What is your training availability?:
Dogs 2 Vets Application
Part 3 Home Life
PLEASE ANSWER THE FOLLOWING QUESTIONS
Please describe a typical day (if at work or school, describe job duties/school classes)
What are your hobbies? How often do you enjoy them?
Do you have a place in your bedroom for your dog to sleep?
No
Yes
N/A
Is there an enclosed space to exercise your dog? If not, how do you plan to exercise your dog daily?
No
Yes
N/A
Do you have a veterinarian in the area to use? Please provide their name and phone number
No
Yes
N/A
Dogs 2 Vets Application
Part 4 Disability Specific Information
PLEASE ANSWER THE FOLLOWING QUESTIONS
Month
When were you diagnosed with the disability?
Day
Year
If applicable:
MST
TBI
PTS
Do you use any equipment to assist you with any disability?
Yes
No
N/A
Is anyone outside of your home involved in your daily care?
Yes
No
N/A
Is your PTS/MST service connected?
Yes
No
N/A
Do you have a disability rating?
Yes
No
N/A
Are you in active therapy for PTS/MST?
Yes
No
N/A
Anger Outbursts
No
Yes
Do you have any of the following behaviors?
Fears/Anxiety
Headaches/Migraines
No
Yes
No
Yes
Insomnia
No
Yes
Forgetfulness
No
Yes
Lack of Inhibition
No
Yes
Lack of Patience
Yes
Depression
No
Yes
Commitment Issues
No
Yes
Pain Management Issues
No
Yes
Ability to Accept Criticism
No
Yes
No
Other
How many times a week do you go by yourself to a public place?
What kind of places do you go (supermarket, doctor’s office, VA, park)?
Do you require a companion to go with you?
Yes
No
Are you willing to progress in training from quiet settings in public to more intense ones in progressive
No
Yes
steps?
Are you, or have you been in a drug and/or alcohol program in the last 5 years?
No
Yes
In what ways do you consider yourself independent?
In what ways do you consider yourself dependent?
Dogs 2 Vets Application
Part 5 Capabilities & Limitations
PLEASE ANSWER THE FOLLOWING QUESTIONS
Poor
Good
Fair
Upper body mobility
Lower body mobility
Dexterity
Arm strength
Endurance
Light sensitivity
Temperature sensitivity
Pain tolerance
Reaction time
Vision
Speech
Balance while walking
Hearing
Part 6 Future Plans
How do you anticipate the dog will affect your life?
What do you want your dog to do for you in the home and/or in public?
What are your plans for the future? School, employment, relocation, volunteering, activities, etc.
Comments / Concerns:
Submit
Excellent