Program
Application
First name:_______________________ Last Name:____________________________
Address:_________________________ Apt. Number:__________________________
City:____________________________ State, Zip:_____________________________
Home Phone: (
)_________________ Fax: (
)______________________________
Place of Employment:________________________________________________________
Address:_________________________ Suite Number:__________________________
City:____________________________ State,
Zip:_____________________________
Work Phone: (
)__________________ Fax: (
)______________________________
Nearest Relative:____________________________________________________________
Address:_________________________ Apt. Number:___________________________
City:____________________________ State,
Zip:______________________________
Home Phone: (
)_________________ Work Phone: (
)________________________
What is your primary
disability?________________________________________________
What caused your disability?___________________________________________________
Please list secondary
disabilities, if any: ______________________________________
__________________________________________________________________________
At what age were you disabled?_______ Is your disability progressive? Yes
No
Date of Birth:___________
Approximate weight:_________
Approx. Height:________
Sex: Male Female
Circle all that apply:
What are the effects of
your disability?
Hearing
Loss Spasticity Speech Impairment Reduced Stamina
Limited
Mobility Memory Loss Slowed Development
Vision
Impairment Muscular Weakness Coordination Problems
Other:______________________________________________________________
Do you have any problems
with...
Allergies
Chronic Pain Heightened
Emotions Depression
Seizures
Skin Sensitivity Balance Brittle
Bones
Heat/Cold
Sensitivity Other:_____________________________________
Do you use an aid or
assistive device?
Prosthesis
Leg Brace Power Wheelchair Manual
Wheelchair
Wrist
Brace Hearing Aid Crutch/Cane
Other:______________________________________________________________
What kind of assistance
dog are you looking for?
Service Hearing Social/Therapy
With whom do you live?
(Check all that apply)
Alone With parent(s) With
spouse or significant other
With
attendant With roommates Other:__________________________
Where do you live?
In a
house In an apartment In a dorm
Other:________________
Do you live with children or have children who visit
regularly? Yes No
If
yes, how many children?___________ What are their ages?________________
Do you have a fenced yard or enclosed area? Yes No
Are you able to travel to the program office for your
interview? Yes No
If no, please explain:____________________________________________________
___________________________________________________________________________
For hearing
dog applicants, please complete the following:
Cell phone#________________________ Preferred cell
method: Voice Text
If necessary, do you have a
hearing friend or relative we can call if we need to contact you? Name____________________________
Relationship_______________________
Phone number______________________
At what age did you lost your
hearing?___________
Cause:_____________________________________
Degree of deafness: Mild Moderate Severe Profound
Please describe you general
health _________________________________________
__________________________________________________________________
Do you have any other
disabilities? Please describe____________________________
___________________________________________________________________
Do you use sign language?_____________________
Do you have oral speech?______________________
What sounds would you like
your dog to be trained to alert you to? ________________
_______________________________________________________________________
_____________________________________________________ _________________
Applicant Signature Date
If the applicant is a minor,
or under guardianship or a ward of the court, the parent or duly authorized
representative is required to sign below pursuant to state and federal law.
Name (first):____________________________ (Last):____________________________
Relationship to applicant:_______________________________________________________
Address:____________________________________________________________________
City:__________________________________ State, Zip:_________________________
Home Phone: (
)_______________________ Fax: ( )__________________________
___________________________________________________
____________________
Parent or Guardian Signature Date
For
office use only
Date Received:__________________________ Received by:________________________
Application Complete: Yes No Meets
Program Requirements: Yes No
Pre-Interview Form Sent:_________________ Interview Scheduled:_________________
Method of Interview: Phone In Person Other:_______________________
Canine Co-Pilots
8539 E. Musket Trail