NEADS Assistance Dog for Classroom, Hospital, Courthouse, or Ministry
Personal Information
First Name
Last Name
Street Address
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State
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Postal Code
Phone Number
Email
Birth Day
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Birth Month
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Birth Year
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2014
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How did you hear about NEADS?
Professional Activities
Occupation
Business Name
Business Street
Business City
Business State
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AK
AL
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
MA
ME
MD
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AS
DC
FM
GU
MH
MP
PW
PR
VI
Business Zip
Business Telephone
Length of Current Employment
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Less than one year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
10+ years
15+ years
20+ years
How long have you been a teacher/therapist/minister?
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Less than one year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
10+ years
15+ years
20+ years
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?
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Yes
No
If so, do you have the support of your CEO (or equivalent) to include a dog in your daily curriculum?
Please select...
Yes
No
Schooling Completed
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Elementary School
High School
College
Graduate School
Phd
Do you volunteer?
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Yes
No
Brief Description of Volunteer Work
Weekly Volunteer Commitment in hours
Living Arrangements
Living Environment
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City
Suburb
Rural
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?
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One Level
Multi-level
Do you own or rent?
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Own
Rent
Rental information
If you are renting, please fill in the details below.
Have you discussed this application with your landlord?
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Yes
No
Do you have written permission from your landlord to own a dog?
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Yes
No
Landlord's Name
Landlord's Phone
Do you live in a house or apartment?
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House
Apartment
If you live in an apartment, please fill in the details below.
What floor do you live on?
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Basement
First
Second
Third or Above
How many units are in your building?
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0
1
2
3
4
5
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8
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10
Is it a single building or a complex?
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Single Building
Complex of Buildings
Do you have a yard?
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Yes
No
Is your yard fenced?
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Yes
No
If you have a yard, please fill in details below.
Does the fence encircle the yard?
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No
Yes
What is the height of the fence?
How many people live with you?
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0
1
2
3
4
5
6
7
8
9
10 or more
Please list below name, relationship and age of people living with you:
Do you have frequent visitors?
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No
Yes
Do you or anyone in your household have a dog now?
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Yes
No
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?
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Yes
No
What types of transportation do you use?
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Car
Train
Bus
Van
Plane
Are you allergic to cats?
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No
Yes
Are you allergic to dogs?
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Yes
No
Is anyone in your household allergic to dogs?
Please select...
Yes
No
Dog Care
Please tell us about your history in caring for a dog.
Have you had a dog before?
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Yes
No
If so, what breed(s) and when? What happened to the dog(s)?
Have you ever sold, given away, or surrendered a pet?
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Yes
No
If so, why?
How often would you leash walk your dog?
Is there a place at your employment to exercise your dog?
Please select...
Yes
No
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?
Please select...
Yes
No
Do you travel a lot?
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Once a month
Once every six months
Once a year
Would you take your dog with you on trips?
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Yes
No
Would you take your dog to social events?
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Yes
No
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.
Please select...
Yes
No
When would you be able to start training with your Assistance Dog?
Have you attended dog obedience classes?
Please select...
Yes
No
If so, what level?
Do have have dog handling experience?
Please select...
Yes
No
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
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Spouse
Father
Mother
Brother
Sister
Aunt
Uncle
Cousin
Friend
Other
Application Confirmation
By checking this box, I attest that all information in this application is true and correct to the best of my knowledge.
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