Application (Weebly form)

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

Emergency contact phone number: *

What Branch of Service were you in? *

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

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

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? *

Are they current on their vaccinations? *

Yes No Not Applicable

What size dog are you looking for? *

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? *

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