Applying for a service dog from Promising Partners Assistance Dogs is a big step.  However, it is just the first in a series of steps to receiving a dog. 

 What you should know before you apply…

·         Promising Partners does not place service dogs with children under the age of 16.

·         We will not train your personal pet to be your service dog.

·         If selected to receive a dog from Promising Partners, we ask that you pay a $250 placement fee.

·         Applying for a dog now does not mean you will have it tomorrow.  Finding the right dog for you is an important process and you should expect the process to take no less than 6 months.  (To date 11/30/2006 we are just starting to take in our puppies in training which means we expect our first placements to take place around 1 1/2 –2 years from now.)

It is important to us that the person applying for the dog is the one who completes this application.   If unable to do so, please complete it using the applicant's own words. If at all possible, attach a recent photograph for our files; this helps us put a face to a name. If it would be easier to video or audio tape the replies, please feel free to do so. 

Once the application has been reviewed, an initial interview will be scheduled or we will send directions for making a video interview. This will assist us in training the dog to specifically meet its partner's needs.

If there are any questions please do not hesitate to contact us at 620-564-2993.  We look forward to hearing from you. 

Please initial when read___________________

SERVICE DOG APPLICATION

 

Name:

Date: 

Address:

County:

Phone: (H)

(W)

Email:

Birthdate: 

Weight: 

Height:

Social Security Number:

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Phone Number:

Presently:

Student

Employed

Unemployed

Other

If student please list current grade, school address, & principal’s name: 

If employed list occupation, employer, employer's address, & name of supervisor.

Referred By:

Please list other assistance dog organizations you have applied to and your status with them:

Type of disability and age of onset.

Do you smoke?

Does anyone in your household smoke?

Do you use a wheelchair?

If so is it electric or manual? 

Do you use any other mobility aids?

Do you require the assistance of an aid or family member for daily living skills?

If so what are that person’s responsibilities and number of hours worked?

Do you currently own and operate a motor vehicle? 

Do you have any pets?

Please list:

Please list your sources of income:

Please list all the people residing in your home and their ages: 

Do you have a fenced in yard?

Do you have any experience working with animals? 

If yes please explain:

Would you be able to come to the organization for the required three-week training course?

Please include with your application a letter of recommendation written by someone outside your immediate family.

PLEASE COMPLETE ESSAYS ON SEPARATE PIECES OF PAPER

Essays must be in the words of person applying for dog.

DESCRIPTION OF RECIPIENT ESSAY

The purpose of this essay is to enable Promising Partners to understand your physical traits, lifestyle, disability, activities and personality. Through a detailed description of yourself, your home, your family, and your activities, we can better establish the suitability of your situation for a service dog. Please be as precise and comprehensive as possible. Use as much space as you feel necessary for us to get to know you!

MEANING AND FUNCTION OF A SERVICE DOG ESSAY

Please explain why you feel a service dog would be beneficial. Which of your daily activities could be accomplished more easily and independently with the help of a service dog? How do you feel a service dog could help you other than with physical tasks? What do you feel you will be able to offer the dog in return?

If you have further questions regarding the Canine Partners for Life application or program, or if you need assistance completing this application please call.

Print out, complete and return questionnaire to:

Promising Partners Assistance Dogs, Inc., P.O. Box 364, Ellinwood, KS 67526