Svc Program App

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 $150 deposit required to confirm the Discovery meeting.
Your Full Name

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

Area Code Phone Number
Email *
Address

Street Address

Street Address Line 2

City State

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

Month Day Year
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
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? *
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, etc Avoid moving objects: bicycles, cars, etc SIT at curbs HALT to indicate stairwells or drop-offs Find a room exit Lead to a doorknob Pick up / locate telephone Pick up / locate keys Pick up / locate pill bottle Pick up / locate writing instrument Fetch newspaper Fetch beverage from the refrigerator Retrieve dishes from cabinet Load dishwasher Load clothes washer Pick up dirty clothes and place in basket Alert to the sound of: doorbell Alert to the sound of: door knocking Alert to the sound of: smoke alarm Alert to the sound of: phone ringing Alert to the sound of: alarm clock Alert to the sound of: baby crying Alert to the sound of: timers - microwave, etc Alert to the sound of: police, fire, ambulance Alert to the sound of: vehicle honking Alert to the sound of: personal equipment alarms When returning home after dark, the dog will turn on lights Carry a note or object to another specified person
Open / close door Pick up cane Turn on light switch Turn off television Locate lost owner Carry in groceries Unload groceries Fetch food bowls Fetch slippers, shoes, etc Follow laser pointer to specific item Fetch wheelchair Carry item up and down stairs Brace to provide balance stability Give money to store clerk, delivery person, etc Open cupboards Remove socks Open and close draperies Pull blanket over owner Place paralyzed limb back onto bed, chair, etc Pull owner up with a strap, then brace Assist owner getting in and out of bathtub Transport owner items in a backpack Bark for help, on command Turn off / snooze alarm clock Wake up owner and turn on light for nightmare Alert to presence of others Provide alternate focus for sensory overload Take attention off owner - social phobias Snuggle/nuzzle for tactile accompaniment Bring tissues Lick tears Interrupt compulsive behavior Initiate 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..."
Schedule a time to chat with us - submissions without a scheduled session will be discarded.

**Important** The scheduling window below scrolls independently of the rest of this form. Don't forget to submit this form at the bottom of the page once you have completed your scheduling!
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Service Dog Training Program Application

Schedule a time to chat with us - submissions without a scheduled session will be discarded.