ECAD's Train-the-Trainer Career Program

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Page 1 - General Information

I wish to register for the following program(s):

Module 1: Assistance Dog Training. A 5 1⁄2 days a week for 5 weeks, Introduction to teaching dogs to assist. Program Cost: $6,000 (Includes Classroom Materials).Module 2: Clients Placement Training. A 3 week program on matching and placing service dogs. Program Cost: $3,500 (Includes Classroom Materials).Module 3: Early puppy development. A 3 week program, on developing the puppy to become a service dog. Program Cost: $3,500 (Includes Classroom Materials).

On-site housing with 2 students per bedroom, shared bathroom, kitchen, and living space is available on a limited, first-come basis.

I do not need on-site housing.I would like on-site housing for the following module(s):Module 1: Duration, 5 Weeks. Housing cost: $1,500Module 2: Duration, 15 Days. Housing cost: $1,000Module 3: Duration, 15 Days. Housing cost: $1,000

Salutation

First Name

Last Name

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Preferred Email

Personal Email

Work Email

Other Email

Address

City

State

Zip Code

Gender

Date of Birth

MM/DD/YYYY

License or State Id#

Have you ever been convicted of a felony?

Criminal History

Please explain

Controlling Charge

Date of conviction

Please provide an additional information you feel relevant

Character References

Reference 1 Name

Reference 1 Email

Reference 1 Phone

Reference 2 Name

Reference 2 Email

Reference 2 Phone

Page 2 - Experience

Education History

Highest Education Level Achieved

Date of Graduation

Institution

Degree

Work History

Currently Employed

YesNo

Company Name

Title

Term of Employment

Please briefly describe your role and responsibilities.

Military Branch

Military Rank

Years of Active Service

Volunteering

Have you volunteered before?

YesNo

What is the name of the organization you volunteered for?

What did you do as a volunteer? (List tasks/functions)

Experience

Do you have any experience working with or educating the following: (Check all that apply)

DogsPeople with DisabilitiesGroup TrainingNone of the Above

Dogs - Please explain the capacity of your experience.

People with Disabilities - Please explain the capacity of your experience.

Group Training - Please explain the capacity of your experience.

Page 3 - Goals & Objectives

What interested you about ECAD's Train-the-Trainer Career Program?

What would you like to achieve from attending ECAD's Train-the-Trainer Career Program?

What is your career goal?

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