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Service Animal Application

Welcome to California Service Dog Academy's Application. Please complete all fields and ensure you

review all information carefully. You will receive updates regarding the status of your application via your preferred form of contact you list on your application below. California Service Dog Academy will process your application within 4-8 weeks of it being received by our organization.

You may remove yourself from the application process or the program at any time by submitting your request in writing and sending it in to our organization in either of the ways detailed below:

- via email to info@californiaservicedogacademy.org

- via Certified Mail to:

California Service Dog Academy

3330 S. Fairway

Visalia, CA 93277

By completing this application, you consent to proceed with California Service Dog Academy’s application process and receive communications regarding your application status. If this application is being completed for a minor under the age of 18 or an adult deemed not legally competent, a parent or legal guardian must complete the application.

The information within this application is protected under the Health Insurance Portability and Accountability Act (HIPAA). Please see CSDA's Notice of Privacy Practices.

Type of Application

Although you are welcome to submit an application, CSDA has a very long waiting list and is not likely able to provide a dog for you at this time.

Is this application for you or another person?

What is this person's relationship to you?

Is this person a minor or deemed legally incompetent?

Are you this person's parent or legal guardian? (If you are the parent or legal guardian, please enter YOUR email below. You are REQUIRED to digitally sign this application and all other documents. You MUST list yourself as Emergency Contact #1

Client Email Address

Birthday

Client First Name

Client Last Name

Street Number and Address

City

State

ZIP Code

Primary Phone Number

Numbers only - no hyphens or spaces

Primary Phone Type

Secondary Phone Number

Numbers only - no hyphens or spaces

Preferred Method of Contact:

Certified MailEmailPhone

Have you previously applied for a dog with us or through another program?

NoYes, with CSDAYes, with another organization

Which organization?

How did you hear about CSDA's programs?

General Information

What is your height? (Feet)

Height (Inches)

What is your weight? (Pounds)

What gender do you identify with?

MaleFemaleNon-binaryOther

Preferred Pronouns:

Dog Information

California Service Dog Academy offers the following types of dogs:

1. Service Dog - CSDA Bred: Dogs that are bred in our programs go through a litany of checks and tests to ensure they will have a long a successful career as a service dog for their human companions. CSDA Bred Dogs meet our highest standards and come from linages that we carefully select for temperament and health. As with all ADA compliant service dogs, these dogs are trained to perform tasks for a person with a disability.

* These dogs ARE granted full public access under ADA

* These dogs typically have 500 or more hours of training

* These dogs have a full cost of $20,000 or more without grants, sponsorships, or other aide.

Examples of Service Dogs include the following types; Alert Dogs (Allergy, Medical, Diabetic, etc...), Autism Assistance Dogs, Mobility Support Dogs, Psychiatric Support Dogs (PTSD, Anxiety, Depression, etc... )

2.Emotional Support Dog (ESD) / Skilled Companion Dog: A skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. However, emotional support dogs do not have the proper training to be deemed by our organization to be a service dog and would not be recognized under ADA.

* These dogs are NOT granted full public access under ADA but some state laws may grant access

* These dogs typically have less than 500 hours

* These dogs have a full cost between $5,000 - $10,000 without grants, sponsorships, or other aide.

Please select the type of dog you are interested in:

Do you have your own dog that you would like to have evaluated to become your possible service dog?

Your Dog's Information

Dog Name

Dog Breed

Dog Age

Dog age in years

Dog Gender

Dog's Prior Training

Does your dog have a history of aggression or other behavior issues? Please be as detailed as possible.

Does your dog have any physical health issues or concerns? Please include as much information as possible.

Please give any additional information about your dog below that you think is relevant to them becoming a service dog

Emergency Contact Information

Please note that each contact listed will need to provide written evidence that she/he is knowledgeable of your service dog application, they support the process and placement of a service dog and can provide a temporary home for the service dog should an emergency arise. CSDA may reach out to your contacts to obtain the written evidence and validation of their addition to your contact list. By placing your emergency contacts on this form you are acknowledging that they are supportive of your involvement in this program and agree to provide assistance to you when needed or requested.

Emergency Contact #1

Full Name

Relationship to Applicant

Phone Number

Numbers only - no hyphens or spaces

EC #1 Email Address

Emergency Contact #2

Full Name

Relationship to Applicant

Phone Number

Numbers only - no hyphens or spaces

EC #2 Email Address

Military Affiliation

Are you in or have you served in the military?

YesNo

What branch of the military do you represent?

Are you active duty or discharged/retired?

ActiveDischarged/Retired

Other Military Service

General Disability Information

What type of disability do you have?

What date did your disability start?

Is your disability progressive?

YesNo

Do you have any other medical considerations or diagnoses we should know about?

What would you like to accomplish with your service dog? What are some improvements you would like to see?

Criminal Background Check

California Service Dog Academy conducts background checks on applicants through a third party organization. California Service Dog Academy does not accept applications from individuals with a history of violence against animals or people, including sexually violent crimes or arson. Separate Authorization and Disclosure forms will be sent regarding this background check. If you do not agree to receive information regarding a background check, CSDA may not be able to move forward with processing your application.

Do you agree to receive information regarding a background check including the Disclosure and Authorization forms from CSDA?

YesNo

Background Check Information

By completing this application you understand that you are NOT consenting to a background check to be conducted. Separate Authorization and Disclosure forms must be completed before a background check is conducted. This information is being collected to verify your identity and confirm you are agreeing to receive communications from CSDA regarding undergoing a background check. You are not required to provide this information at this time.

Is the above name you used in this application your full name and is it spelled correctly?

YesNo

What is your full name spelled correctly?

Do you have any other names? (Maiden name, name change, etc.)

Driver's License State

Driver's License Number

Social Security Number

Format: 123-23-1234

Required Documentation

The following documents are required to become a part of our Program.

For our Sentinel Dog Program for Veterans, a copy of your most recent DD-214 is required to apply. Please ensure your DD-214 has your discharge status listed. At this time, CSDA is only accepting applicants with an Honorable discharge status.

DD Form 214

Doctor's Note (This must be a letter or document with a Doctor's recommendation that a Service Dog may benefit you with your disability/ies). CSDA requires that you have a note from a licensed healthcare provided that has provided services to you for a minimum of 90 days and is familiar with your disability and can attest to the type and scope of the disability for which you are applying for a service dog as well as your need for a service dog. Please see CSDA's Notice of Privacy Practices.

**A template form to give to your Doctor can be downloaded HERE

By submitting the requested documentation and completing this application, you are granting California Service Dog Academy permission to view and process the information in those documents in order to receive appropriate services from our organization.

Financial Capability

Becoming a service dog handler means being financially capable of caring for a dog for the duration of its life (10+ years). This cost includes, but is not limited to, the provision of annual veterinary care (at minimum), AAFCO-approved dog food, required tags and licensure, purchase of appropriate treats, breed-specific grooming, and any required medical treatments or medications. Costs average $2,000 per year. For more information, please visit the AKC website.

Are you financially capable of caring for a dog long-term?

YesNo

Travel Requirement

California Service Dog Academy's programs require clients to travel regularly for training. Travel to our facility in Visalia, California is required a minimum of two times per month. Travel to other training destinations may be required. By submitting this application, you confirm that you are aware of this requirement and have the means and ability to travel regularly for training. Please note, if you select "No" to the question below, CSDA may not be able to proceed with processing your application.

Are you willing and able to travel to Visalia, California regularly?

YesNo

Required Documentation

The following documents are required to be submitted to become a part of our Program:

A doctor's note stating the type and degree of your disability/ies and your need for a service animal (see below section for more information and template)
An intake questionnaire completed by your doctor (form will be sent after application submission. Please email us to receive a copy of this form prior to application submission if desired)
Proof of stable housing over 6 consecutive months. Acceptable documents include utility bills, a lease agreement, or other legal documents. More information will be sent after your application has been submitted.
Other documents as required or requested by our organization

For our CARE Dog Program for Civilians, an additional letter of reference from a family member or friend is required. The Doctor's recommendation is required at the time of application.

**A template form to give to your Doctor can be downloaded HERE

By submitting the requested documentation and completing this application, you are granting California Service Dog Academy permission to view and process the information in those documents in order to receive appropriate services from our organization.

Thank you!

Thank you for completing your application. Once you click submit you will receive an emailed version of your application with direction on how to edit your application at any time.

Should you wish to withdraw from the application process please call us at 866-382-9917 or email us at info@californiaservicedogacademy.org

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