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Operation at Ease, Inc.
Service Dog Program Application
ITEMS MARKED WITH AN * ARE REQUIRED ENTRIES
*
Indicates required field
Name
*
First
Last
Phone
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email Address
*
Name of an emergency contact person who does not live with you:
*
First
Last
Please provide the name of someone, other than a person that you live with, who will be able to care for your dog temporarily if needed.
Emergency contact phone number:
*
What Branch of Service were you in?
*
If you are applying as a First Responder please answer with the type of first responder you are (i.e.EMS, Fire, Police,)
How many years did you serve? Your answer
*
Can you provide us with a DD214?
*
Yes
No
I am applying as a First Responder
How many people currently live in your household?
*
What is the age range?
*
Do you own your home or rent?
*
Own
Rent
If you own your home can you provide proof of ownership?
*
Yes
No
you rent can you provide you landlords name and contact information? If so, please do so below.
*
Yes
No
Landlords contact information:
*
Do you have a fenced in yard?
*
Yes
No
This is not a requirement, it helps us determine the best dog for your lifestyle.
Are you currently receiving any VA benefits?
*
Yes
No
Do you have any health issues that you would like to have a confidential conversation with our application evaluators about?
*
Yes, please contact me to discuss my condition
No, I do not have any health issues to discuss
Health concerns will not prevent you from getting a dog from us, however we need to be aware of any issues that might be a factor in helping us choose the proper dog for you.
Can you provide a letter from a health care provider stating you require or would benefit from a service animal?
*
Yes
No
Have you ever considered hurting yourself or others?
*
Are you currently in any form of counseling? If yes, how often and where do you attend?
*
Are you currently employed?
*
Yes
No
If so, how many hours per week do you work?
*
Will you require your PTS or light mobility service dog to accompany you to work?
*
Yes, always
Yes, occasionally
No, never
How social are you?
*
Very, I leave the house 5 + days/week
Somewhat, I leave the house 3-4 days/week
A little, I levae the house 1-2 days/week
Not very
How often do you exercise?
*
Regularly, 5+ times/week
Often, 3-4 times/week
Somewhat often, 1-2 times/week
Not very often
Do you have any other animals in the house?
*
Please enter yes or no and if your answer is yes enter they type and number of other animals you have. (for example: 2 cats, 1 dog)
Are they current on their vaccinations?
*
Yes
No
Not Applicable
What size dog are you looking for?
*
If you would like us to temperament test your own dog please enter I would like to use my own dog.
Are you willing to commit to attending eight months of dog training classes (one class per week)?
*
Yes
No
What are five tasks you need your service dog to do for you?
*
i.e. buffering in a crowd, deep pressure during panic attacks, bracing/balance support, behavior interruption
Do you believe your current situation will allow you to keep a service dog for at least 8-10 years?
*
Yes
No
Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself).
*
Yes
No
Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you?
*
Yes
No
Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler?
*
Yes
No
Do you agree that your service dog will not be off its leash except in a secure area?
*
Yes
No
Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you?
*
Yes
No
Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight?
*
Yes
No
Will you or a qualified person ensure your service dog gets daily exercise?
*
Yes
No
Will you or a qualified person take full responsibility for cleaning up after your dog in public places?
*
Yes
No
Do we have your permission to contact anyone who is listed on this application if we need further information?
*
Yes
No
When are you available to attend classes?
*
Afternoon
Evening
Either, I am available both afternoons and evenings
The Operation At Ease training center is located in Rotterdam, NY. Upon successful completion of classroom training we begin Public Access training, which is done at various locations in the Capital District. Do you have reliable transportation to get you and your service dog in training to and from all training and public access classes for a eight month period?
*
Yes I will drive myself
Yes, I have someone that will provide me with reliable transportation2
No, I do not have transportation
List three personal references we can contact, Name Relationship Phone Number
*
Please provide us with a name and number of someone who can take care of your dog in your absense (or in the event of an emergency)
*
I understand that, if I do not complete this program in it's entirety, my dog will not be designated as an Operation at Ease, Inc. trained service dog. It will be considered my pet and will remain in my care.
*
By checking this box I certify that I fully understand and agree to these terms.
I _____________________________(print name) have answered all sections honestly and to the best of my ability.
Signature (Print this form with completed answers and we will have you sign below in person):
*
SUBMIT APPLICATION
About us
OAE in Action
OAE in the News
Our Location
FAQs
Veterans
Service Dog Application
Forms
Mental Health Resources
Request Therapy Dog Visit
First Responders
Service Dog Application
FAQs
Forms
Request Telehealth
Register for Drop in Classes
Purchase
Corporate Sponsorships
Our Sponsors
Events
Volunteer Opportunities
Telehealth Volunteers
Classes
FAQs
Support Us