Service Dogs of Virginia - Autism 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

Height: *

Weight *

What is your child's full diagnosis? *

Please include any secondary diagnosis, related or unrelated:

Mother's Name *

Father's Name *

Street Address *

Current living arrangements: * With parentsWith guardianGroup homeOther

Group home:

name/location

Other:

please explain

City *

State *

Zip *

Home Phone:

*( )

* -

*

Work Phone:

( )

-

Cell Phone:

( )

-

Email: *

Occupation:

Employer:

Supervisor:

Years at this job:

Hours per week:

Annual Household Income:

Guardian Information (if different from parent)

Name:

Street Address

City

State

Zip

Phone:

( )

-

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

Education

Name of School

Street Address

City

State

Zip

Phone #:

( )

-

Do you want your service dog accompany your child to school? YesNo

Does your child have a 1:1 Education Assistant while at school? YesNo

How often?

What type of class room does your child attend?

Have you discussed this application with your principal/administration? YesNo

If no, do you plan to? YesNo

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 does your child leave home a day?

A week?

How many people does your child 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?

Does your child like dogs? YesNo

If yes, how do you know this?

Do you currently have any pets? YesNo

	Species	Breed	Age	Live Inside / Outside	Spayed or Neutered?
Pets
Pets

Describe your child's activity level: LowModerateHigh

Describe your child's activity mobility:

When do you get out of bed in the morning?

Describe your daily schedule.

What time do you retire in the evening?

Your Family and a Service Dog

Describe the ways you believe a Service Dog can assist your child. 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?

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?

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.

Do you have any concerns regarding owning a service 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:

*( )

* -

*

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 contact these references? YesNo

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.

Please list all medications your child takes:

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

Medical Information

* YesNo

Primary Physician

Phone

Address

Have you discussed this application with your doctor? * YesNo

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

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

Describe any/all hospitalizations in the last 3 years:

Is your child's mobility or coordination limited? If yes, how?

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

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?

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