Service Dogs of Virginia - Diabetic Alert Dog Application

Instructions:

Before filling out this application, please read the Application Overview, Criteria for Applicants, Application Process summary, and Estimate of Expenses to own a service dog.

Please confirm by checking the box below: * Yes, I have read and understand the above.

Should you have any questions, please contact Director Peggy Law at:

Phone: (434) 295-9503
Email: info@servicedogsva.org
Mailing address: PO Box 408, Charlottesville, VA 22902

Today's Date: *

use format dd/mm/yyyy

Referred by:

SDV ONLY places dogs with individuals living in the state of Virginia. Are you a current and permanent resident of Virginia? If No, please go to www.assistancedogsinternational.org to find an organization in your state or makes placements in your state. * YesNo

PERSONAL INFORMATION (To be completed by parent or guardian)

Name: *

Birth Date: *

Current Age: *

Gender * MaleFemale

Mother's Name *

Father's Name *

Street Address *

City *

State *

Zip *

Home Phone:

*( )

* -

*

Work Phone:

( )

-

Cell Phone:

( )

-

Email: *

Height: *

Weight *

How long have you had Diabetes? *

What Type? Type 1Type 2

Please include any secondary diagnosis, related or unrelated:

Guardian Information (if different from parent)

Name:

Street Address

City

State

Zip

Phone:

( )

-

Current living arrangements: * With parentsWith guardianGroup homeOther

Group home:

name/location

Other:

please explain

Are there any other individuals with disabilities in your household? YesNo

School/employment information:

Are you presently: A studentEmployedUnemployedOther

Highest level of education completed:

Occupation:

Employer:

Street Address

City

State

Zip

Hours per week:

Years at this job:

Phone #:

( )

-

Supervisor:

Have you discussed this application with your employer? YesNo

If no, do you plan on taking your service dog to work with you? YesNo

How often?

If yes, when will you speak with your employer about your dog?

Annual Household Income:

Lifestyle & Living Situation

Describe your house and yard area:

Do you live in a: HouseApartmentOwnRent

If you rent, have you discussed this application with your landlord? YesNo

Do you have a fenced yard? YesNo

If yes, please describe (size, type of fencing, terrain, etc.):

If not, would you be willing to install one? YesNo

Do you have many visitors to your home? YesNo

Do any visitor’s pets come to your house? YesNo

Do they come inside? YesNo

Where would the dog be while you are away?

How many hours per day would the dog be alone?

How often do you travel?

Would you take the dog with you on trips?

List all people residing in your home:

name, relationship, age

How many times do you leave home a day?

A week?

How many people do you interact with daily?

Weekly?

Describe your neighborhood (i.e., busy road, neighbors close by, dogs/cats running free:

Have you ever owned a dog before? YesNo

If yes, when and for how long?

Do you or any members of the household have allergies to dogs?

If yes, how do you plan to address this?

Do you like dogs? YesNo

Do you currently have any pets? YesNo

If so, please list: Species, Breed, Age, Spayed/Neutered? Live Inside or Out

Describe your activity level: LowModerateHigh

Describe your activity mobility:

Is mobility or coordination limited? How? Please be specific and detailed.

You and a Service Dog

Describe the ways you believe a Service Dog can assist you. What are your hopes, fears, goals?

Do you have any experience working with animals? If yes, please explain.

Will your family accept a trained dog as an equal partner in your house? YesNo

Where will your dog be taken for toilet requirements?

When do you get out of bed in the morning?

What time do you retire in the evening?

Who will help you with the dog’s care if you are sick and cannot get outside:

name

Phone:

( )

-

Proximity to Your Home

Where will the dog be exercised and have playtime?

Describe your daily schedule.

Do you have any concerns regarding owning a service dog?

How much exercise, on average, per day, do you think that a dog needs?

Describe your definition of exercise and an exercise plan you could implement for your dog.

Are you willing to participate in on-going training sessions once you receive a Service Dog? YesNo

If no, why not?

Are you able to come, every day, for one week, to a training class in Charlottesville? YesNo

Name: *

Street Address *

City *

State *

Zip *

Phone:

*( )

* -

*

Name: *

Street Address *

City *

State *

Zip *

Phone:

*( )

* -

*

Name: *

Street Address *

City *

State *

Zip *

Phone:

*( )

* -

*

May we contact these references? YesNo

Please have one personal reference (may be an individual listed above) submit a written letter of recommendation to: Service Dogs of Virginia, PO Box 408, Charlottesville, VA 22902. This letter will need to be received in order for your application to be considered complete.

May we have permission to contact your physicians and/or other health care providers who are currently treating you (physicians, counselors, physical therapists, etc.) for information on your medical condition and for guidance in placing a dog in your home? If yes, please complete and sign a medical release form (attached) for each physician or health care provider you see on a regular basis and include with your application. YesNo

Please list other service dog organizations to which you have applied and your status with them.

Do you certify that all information is correct and complete? YesNo

Medical Information

Primary Physician

Address

Phone

Is s/he in favor of your getting a Service Dog? * YesNo

Have you discussed this application with your doctor? * YesNo

Describe your disability and age of onset:

Please list all medications you take

Please list ALL physicians who currently treat you and list their field of specialization

How often do you have hypoglycemia (low blood sugar?

How do you treat your hypoglycemia?

What are your symptoms?

Do you recognize symptoms when they occur? YesNo

What other methods have you tried to assist with recurrent hypoglycemia?

Have you ever been monitored with a continuous glucose monitoring system? Yes

Do you wear an insulin pump?

How often do you monitor your blood sugar?

Do you check your blood glucose during a “low ”episode? YesNo

Do you have Glucagon in your home? YesNo

Does another family member know how to administer it? YesNo

Have you ever met with a Certified Diabetes Educator? YesNo

How do you think a diabetic alert dog would be helpful to you?

What does your family and other household members think of you considering a service dog?

Do you use a wheelchair YesNoManualPower

Will you want your dog to help support you while you are walking or getting up? If so, describe:

Are you restricted in the use of your hands or arms? YesNo

If yes, please describe:

Is one side of your body stronger than the other? RightLeftBoth same strength

On which side would you want the dog to work most of the time? RightLeft

Are you able to issue voice commands in a clear, audible voice? YesNo

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

If yes, please indicate each individual's name, general duties or tasks performed, and hours worked per day.

Do you anticipate future surgery or hospitalization for any reason? YesNo

If yes, please explain:

Are they willing to assist with the daily care of a Service Dog, if needed? YesNo

Describe any/all hospitalizations in the last 3 years:

Please describe any cognitive difficulties (such as memory problems, inability to concentrate) that would affect your ability to manage a Service Dog or complete team training:

Would any of your current medications impair your ability to manage a Service Dog, attend team training or impact learning how to work with your dog? YesNo

If yes, please describe:

Fundraising with SDV

Are you and your family aware that SDV is a non-profit organization that relies on donations to continue supplying quality trained service dogs at no cost and that it costs SDV approximately $18,000 to raise, train, place and provide follow-up for each dog? YesNo

Applicants and their families are expected to assist in the acquisition of funding for their service dog through family donations, corporate contacts, fundraising events and assisting SDV with public relations and marketing. Are you willing to assist SDV raise funds for your future service dog? * YesNo

Do you have any fundraising ideas you would like to share with SDV? Do you have any other information or concerns that might assist SDV in the acquisition of funding?