Svc Program Application

Service Dog Training Program Application
Before completing this form, please review the following:
1. For our Puppy or Adult Owner Trained Service Dog Programs, if you reside a good distance from our training center in Holderness, NH, please be sure you are willing/able to make the drive for the duration of the program.
2. Your dog isn't aggressive, shy, anxious or fearful.
3. You are able to pay the $100 retainer required to confirm the Discovery meeting.
Your Full Name

First NameLast Name
Your Full Name
First and Last
First Name*
Last Name*
Mailing Address*
City*
State*
Zip Code*
Phone Number*

Area CodePhone Number
Email*
Address

Street Address

Street Address Line 2

CityState

Zip Code
If your dog will be used for mobility tasks, please provide your height and weight
Dog's Name-enter "none" if you don't currently have a dog*
If "none," when do you anticipate having a dog?
Dog's Breed
Dog's Birth Date

MonthDayYear
Date
Dog's Birth Date
MM/DD/YYYY Format
Dog's Weight
Dog's Gender
Indicate spay/neuter
Any Allergies?
Please list all the dog's current vaccinations and next due dates.
Rabies, Canine Cough and Distemper vaccinations are required
Describe any training the dog has*
Describe any anxiety, aggression or fearfulness your dog has. *
Do you have high speed internet?*
Do you have a desktop computer?*
Which format would you like for the Discovery Meeting?*

In Person (preferred)Online Meeting
Which program are you interested in?*

Owner Trained Service Dog Puppy (12wks old or less at start of first class)Owner Trained Adult Service Dog (6 months or older at start of first class)Premier Owner Trained Adult Service Dog (Lodge and Train jumpstart)
Please tell us how a service dog would change your life.*
Do you feel that you are capable of training your dog? *
Do you currently have a relationship with a therapist?*
Required for psychological service dog tasks
Please check the skills that would like to train your dog to perform. We will use your selections to aid in creating a customized outline to further refine during our in person meeting.

We provide training for the following conditions:
- Mobility Support
- P.T.S.D.
- Psychiatric Support
- Seizure Response
- Diabetic Alerting
- Reading Assistance
- Hearing Disability
- Stress & Anxiety Conditions
We do not currently train for the following:
- Guide Dogs for the Blind
- Seizure Alerting
- Childhood Autism
- Allergen Alerting
- Epilepsy Alerting
Navigate around obstacles: trees, furniture, etcAvoid moving objects: bicycles, cars, etcSIT at curbsHALT to indicate stairwells or drop-offsFind a room exitLead to a doorknobPick up / locate telephonePick up / locate keysPick up / locate pill bottlePick up / locate writing instrumentFetch newspaperFetch beverage from the refrigeratorRetrieve dishes from cabinetLoad dishwasherLoad clothes washerPick up dirty clothes and place in basketAlert to the sound of: doorbellAlert to the sound of: door knockingAlert to the sound of: smoke alarmAlert to the sound of: phone ringingAlert to the sound of: alarm clockAlert to the sound of: baby cryingAlert to the sound of: timers - microwave, etcAlert to the sound of: police, fire, ambulanceAlert to the sound of: vehicle honkingAlert to the sound of: personal equipment alarmsWhen returning home after dark, the dog will turn on lightsCarry a note or object to another specified person
Open / close doorPick up caneTurn on light switchTurn off televisionLocate lost ownerCarry in groceriesUnload groceriesFetch food bowlsFetch slippers, shoes, etcFollow laser pointer to specific itemFetch wheelchairCarry item up and down stairsBrace to provide balance stabilityGive money to store clerk, delivery person, etcOpen cupboardsRemove socksOpen and close draperiesPull blanket over ownerPlace paralyzed limb back onto bed, chair, etcPull owner up with a strap, then braceAssist owner getting in and out of bathtubTransport owner items in a backpackBark for help, on commandTurn off / snooze alarm clockWake up owner and turn on light for nightmareAlert to presence of othersProvide alternate focus for sensory overloadTake attention off owner - social phobiasSnuggle/nuzzle for tactile accompanimentBring tissuesLick tearsInterrupt compulsive behaviorInitiate play with owner
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
How did you hear about our service dog training? Please be specific.*
Are you over 18 years old?*
Choose one
Are there any others involved in your decision to enroll?
To prevent "I need to talk to my..."
After submitting this form, you will be given choices for a date and time to schedule a discovery meeting with us. Submissions without a scheduled meeting will be discarded.
Should be Empty:

Service Dog Training Program Application

After submitting this form, you will be given choices for a date and time to schedule a discovery meeting with us. Submissions without a scheduled meeting will be discarded.