NEADS Assistance Dog for Classroom, Hospital, Courthouse, or Ministry

Personal Information

First Name

Last Name

Street Address

City

State

Postal Code

Phone Number

Birth Day

Birth Month

Birth Year

How did you hear about NEADS?

Professional Activities

Occupation

Business Name

Business Street

Business City

Business State

Business Zip

Business Telephone

Length of Current Employment

How long have you been a teacher/therapist/minister?

Describe the children and/or adults you are working with (include their disabilities and ages).

Please describe your present responsibilities with the children or adults.

Please describe the setting where you work:

Are there any other animals in your classroom/office, or building?

Have you discussed this with your employer?

If so, do you have the support of your CEO (or equivalent) to include a dog in your daily curriculum?

Schooling Completed

Do you volunteer?

Brief Description of Volunteer Work

Weekly Volunteer Commitment in hours

Living Arrangements

Living Environment

Please describe your neighborhood (for example, busy road, neighbors close by, dogs/cats running).

Do you live in a one level or multi level home?

Do you own or rent?

Rental information

If you are renting, please fill in the details below.

Have you discussed this application with your landlord?

Do you have written permission from your landlord to own a dog?

Landlord's Name

Landlord's Phone

Do you live in a house or apartment?

If you live in an apartment, please fill in the details below.

What floor do you live on?

How many units are in your building?

Is it a single building or a complex?

Do you have a yard?

Is your yard fenced?

If you have a yard, please fill in details below.

Does the fence encircle the yard?

What is the height of the fence?

How many people live with you?

Please list below name, relationship and age of people living with you:

Do you have frequent visitors?

Do you or anyone in your household have a dog now?

If so, what is the age of the dog? male/female? neutered? friendly to other dogs?

Please list other pets (type, age, altered, friendly to dogs?).

Lifestyle

Please tell us about your lifestyle.

What are your hobbies/interests?

Do you smoke?

What types of transportation do you use?

Are you allergic to cats?

Are you allergic to dogs?

Is anyone in your household allergic to dogs?

Dog Care

Please tell us about your history in caring for a dog.

Have you had a dog before?

If so, what breed(s) and when? What happened to the dog(s)?

Have you ever sold, given away, or surrendered a pet?

If so, why?

How often would you leash walk your dog?

Is there a place at your employment to exercise your dog?

Where will your dog be kept during the day?

Where will your dog be kept a night?

Where will your dog be taken for toilet requirements at home?

Where will your dog be exercised and have play time?

Who will help with the dog's care if you are sick or cannot get outside?

Helper Name

Helper Phone

Would you let your dog run free outside of an enclosure?

Do you travel a lot?

Would you take your dog with you on trips?

Would you take your dog to social events?

Please list any info that may be of help to us in selecting the proper dog for you.

Your Training With The Dog

All clients need to be trained with their dogs at the NEADS Campus.

I can arrange to take 7 consecutive business days off from work/school to come to the Massachusetts center to train with my dog.

When would you be able to start training with your Assistance Dog?

Have you attended dog obedience classes?

If so, what level?

Do have have dog handling experience?

If so, please explain.

The reason I want a service dog for the classroom/therapy/ministry/courthouse is:

Dog Training

All dogs are taught basic dog obedience and socialized in public and classroom/situations. The following are tasks that a classroom/therapist/minister's responsibility to incorporate the dog and the dog's tasks into his/her curriculum, with their NEADS trainer's guidance.

What tasks do you want your dog to accomplish?

Pickup dropped articles?

Retrieve objects off counters, tables, or desks?

Turn lightswitch on or off?

Catch articles thrown to the dog? (bean bags, etc.)

Shake with paw?

Go to your crate? (to use this task an area of the classroom/office must be provided for the dog's crate.)

Bark on command?

Other tasks?

Emergency Contact Information

Who can we contact in the event of an emergency?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship

Please review the information you have provided. You will not be given the opportunity to edit this information once it is submitted. Thank you!

Contact Information