Application for Service Dog

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Eligibility Requirements for an Assistance Dog:
  1. Have a physical disability, debilitating chronic illness, neurological disorder, or psychiatric disorder that is medically substantiated by a physician or therapist.
  2. Be physically and cognitively capable of participating in the training process, up to one hour per day of training.
  3. Be able to independently command and handle their Assistance Dog.
  4. Be able to meet the emotional, physical and financial needs of the Assistance Dog.
  5. Be in a stable home environment.
  6. Have a realistic plan of use for an Assistance Dog.
PLEASE NOTE:

We currently have a 3 – 5 year waiting list for our service dogs.  We encourage applicants to research alternative training programs in addition to Custom Canines.  Home interviews will be done as dogs become available for potential placements.

Placements are not on a "fist come, first served" basis, but are based on a careful match of skills, needs, and personalities of dogs and people alike.
 
Custom Canines requires a $50 application donation.  This donation is tax-deductible and you will be redirected to a PayPal payment page after completing this application. This $50 application fee is non-refundable. 

This is a detailed application and we highly recommend periodically saving your application by using the "Save my progress and resume later" checkbox and form at the top of the page. You can continue to save and resume/edit your form until it has been submitted. Once submitted, you will no longer be able to access the form. 

You will need to provide a Medical History form to you Primary Care Physician and have them return it directly to Custom Canines. You will receive the Medical History form in the confirmation email you receive after completing this application.

You will be required to upload a photo of yourself near the end of this application.

Required fields will have a red asterisk *.

If you have any questions regarding which type of Service Dog to apply for or about completing the application, please call 844-888-8850 or email to info@customcanines.org

If you have your own dog that you would like to train as your service dog, please select the OWNER TRAINER ACADEMY as the option for the type of dog you are applying for. Thank you very much!

Page 2

Applicant General Information
Please fill these General Information fields for the minor.






Enter height as feet and inches. Ex: 5' 8"

Enter weight as pounds. Example: 155
Parent/Legal Guardian:



Contact Information



















Emergency Contact












Page 3

Military Information


If you do not have a copy of your DD214 go to: https://www.archives.gov/veterans/military-service-records. Or visit your local VA office and they will request it for you

Dog Information










Hold down the Control Key to make multiple selections.





Disability Information
















Equipment Required

Hold down the Control Key to make multiple selections.

Strength Assessment
Rate your physical strength on a scale of 1 to 10
(1 = Least and 10 = Most)

Page 4

Employment Information










Volunteer







Additional Information
Hold down the Control Key to make multiple selections.

Page 5

References
Please fill in personal references. (NOTE: One reference must be a non-relative).

You must provide the names and contact information for two individuals who have agreed to provide support to you and your dog. These individuals must agree to provide an immediate and temporary home for the dog should an emergency arise.
Reference 1











Valid entry 0 - 99
Valid entry 0 - 11









Reference 2

















Valid Entry 0 - 99
Valid Entry 0 -11



Page 6

Household Information
Names and ages of people living in the home and/or taking care of the applicant on a regular basis. Use the "Add another household member" link below to add multiple household members. 


Enter as MM/YYYY


















Enter height as feet and inches. Ex: 3' 8"






Hold down the Control Key to make multiple selections.

Page 7

Current Pets







Pet History
Add all animals (birds, cats, dogs, etc.) you once owned but no longer own, since you turned 18. Use the "Add a previous pet" link in the bottom right of this section to add each pet. 








Page 8

Veterinary References
Please list any veterinary reference(s). Please include current & previously used veterinarians used for your current pets. If you currently do not have a vet, please list the vet you plan to use for your new CCSDA. You must call your veterinarian and inform them that we will be calling to check on your pet's records.

You should do this soon after receiving confirmation from us that we are processing your application, otherwise it may result in a delay in processing your application. You have to have your vet reference processed in order to be eligible to work with a Custom Canines Service Dog candidate. Please inform your vet that you are authorizing the release of these records/information to the CCSDA representative who calls them. Thank you.








Service Dog Care



Page 9

Personal Interests, Skills & Activities
Please tell us in your own words




Page 10

Photo
CCSDA Application and Placement Policies APPLICANT AGREEMENT

I certify that the information I provided in this application is true and correct.

I understand that to complete the processing of this application, a visit to my home will need to be scheduled by a representative of the organization. All members and pets living in the household must be present at the time of the visit. A visit to your workplace, if you are applying for a full service dog, may also be conducted.
I authorize Custom Canine Service Dog Academy to contact any and all references to verify the information that I have provided. 

I acknowledge that any misrepresentation or falsehoods will disqualify our application. I also acknowledge that any misrepresentation/falsehood may result in termination of the placement.  

•       I grant permission to Custom Canines Service Dog Academy, Inc. to take photographs, images, and audio or visual recordings of me, including my image or likeness, and I consent to the use of those photographs, images and recordings for the purposes of publication or any other lawful use in conjunction with Custom Canines Service Dog Academy, Inc.'s activities in any manner and medium, including, without limitation, in print or on the Internet. I acknowledge that Custom Canines Service Dog Academy, Inc. shall own those photographs, images, and other recordings, and any other intellectual property. I further understand and agree that I shall receive no payment or royalty as a result of the use or publication by Custom Canines Service Dog Academy, Inc. (or its designee) of any photographs, images, or recordings, nor shall I be entitled to receive notices of such use or publication.
 
•      CCSDA reserves the right to refuse or deny any application.

CCSDA will keep your application on file for one year.  After that you will be required to fill out a new application.

Applicants must live within the CCSDA service area.

CCSDA may require further medical information not included on this initial application in order to process your application for a CCSDA Service Dog.

All applicant information will be kept confidential and the property of CCSDA.

Acceptance of this application does not guarantee a placement with CCSDA, or a placement within any given time frame.  Placements are not on a “first come, first served” basis, but are based on a careful match of skills, needs, and personalities of dogs and people alike.

Applicant acceptance is decided without regard to race, religion, gender, or sexual orientation.

I agree that I will attempt to help CCSDA in other ways as I am willing and able: with potential recipients or volunteer trainers in the training room, in fund raising efforts, in communication with the public or other clients and volunteers, etc.

I understand that any financial gift I may choose to donate to CCSDA is fully tax deductible.

I understand that a CCSDA dog is a helper to me but not responsible for my health or safety either by protection in home or public, alerting to dangers, or alerting others that I may need help, or delivering medications to me.

I understand that I am responsible for the health and well-being of the service dog by providing appropriate veterinary care, grooming, high quality food, exercise, licensing, and safety.

I understand that all service dogs in public must be on leash, unless in a dog- designated and secure off-leash area. 

I agree to have my CCSDA service dog wear his/her vest in public and carry the ID card with me for purposes of identification as a CCSDA service dog.

I agree that any cost for my own travel or my own accommodations or meals during the placement process is my own financial responsibility and not covered by CCSDA.

I understand that my own pets must meet the behavioral and health standards of CCSDA in order for a placement to occur.

I agree not to add a new pet into my home in the first two years of placement.

I agree to participate in Public Access testing on a periodic basis as determined by CCSDA.

I agree to fully participate in home visits, interviews and training sessions as directed by CCSDA during the application/placement process.

I understand that at any time during the placement process; if the CCSDA staff determines I am unable to meet the standards to manage care and safety for the service dog, CCSDA reserves the right terminate placement activities.

The CCSDA Board of Directors reserves the right to change these policies at any time.

I agree that this dog Is the property of CCSDA and I/we will not GIVE, SELL, TRADE, ABANDON, SURRENDER OR OTHERWISE TRANSFER ANY TYPE OF OWNERSHIP/GUARDIANSHIP, PHYSICAL POSSESSION OR RESPONSIBILITY for this dog to any other persons/Individuals or organization (shelter/rescue/vet or otherwise) for any reason whatsoever.  

If I can no longer keep the dog I agree to notify Custom Canines Service Dog Academy.  CCSDA will determine the best possible outcome for the service dog, taking into account the circumstances that have caused this inability to keep the dog with the client.  In the case of death or changed medical conditions of the client, it may be determined, if the family wishes, that they retain the dog. 

I agree that CCSDA will be held completely harmless for any medical problems, behavioral problems or any incidents that may occur after placement of the CCSDA service dog.

The recipient agrees to follow support services recommendations or requirements after placement for maintaining training, behavior management, veterinary care, health, care, grooming, Public Access testing for recertification. 

•       I hereby release Custom Canines Service Dog Academy, Inc. and its officers, directors, employees, agents, and volunteers from any liability for any injury to my property or person as a result of or following any accident or occurrences on or about the premises of the School or any facility controlled by Custom Canines Service Dog Academy, Inc., or from any of its operations while I am a client of the School.

I understand and acknowledge that the application fee, Owner Training Academy tuition, if applicable, and any subsequent donations given to Custom Canines Service Dog Academy, Inc. are non-refundable.
Applicant Signature
If the applicant is a minor, under guardianship, or a ward of the court, the parent or guardian is required by law to sign this form.
Please enter your full name
Please enter your full name