Client Application for Certification

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We are excited you want to be a part of Atl graphic of dog on woman's lap doing deep pressure therapy

as!

Our goal is to help as many people who would benefit from a service dog as possible. Please be aware that we are, however, currently limited in how many people we can take on as clients. Based on your current needs, as well as our availability for support, you may be put on a waitlist. If that is the case, we will try to help you find external support until things are ready for you to enter our program and become an Atlas client.

Our network of trainers and team facilitators is constantly growing, and we hope to keep increasing the number of people we can help.

Please complete this form to request certification for yourself and your dog as an Atlas Assistance Dogs certified handler/dog team. All information you provide is confidential and secured with very limited access to only the Atlas staff directly involved in supporting you as a client.

The certified team will either be the combination of a client and dog, or a client, handler and dog in the case where a client is not able to be the primary handler for their dog. We also allow for cases where more than one handler, more than one dog, or more than one client is certified as part of a team. Our standard application form covers the case of a single client and dog team or a single client/handler/dog team. Please request an Additional Handler Form and/or Additional Dog Form as applicable from info@atlasdog.org and submit it with your application. Each client wishing to certify should complete this application and process in full.

Please contact us at info@atlasdog.org if you prefer a version of this application that you can print and fill in offline.

Prior to completing this application, please thoroughly review the following:

user manual icon Our Client Program to see if our program is a good fit for you.

icon of checklist Our Obedience Checklist to see if your dog has the foundation needed to enter our program.

You will need to submit two additional forms as part of your application. You can download them here. You will be able to upload them on the final page of the application.

A Letter of Medical Indication from your medical provider attesting to your need and that a dog would help mitigate your symptoms. A sample is included here.

An Atlas Veterinary Health Form attesting to your dog's suitability for service work, including current vaccination and health records.

Application Information

This information should be completed pertaining to the primary person for whom the dog is mitigating a disability (i.e. the Client). If there is a single handler in addition to the client, their information should also be included in this application. If multiple non-client handlers will be certified please request and complete an Additional Handler form for each handler. If multiple dogs are to be certified, please request and complete an Additional Dog Form for each dog. Please submit these documents with your application, as applicable. If the dog will serve multiple clients, each client should complete their own application and provide their own Letter of Medical Indication. Only one copy of the dog’s veterinary and health information is required.

First Name:

MI:

Last Name:

Pronoun(s):

They/ThemShe/HerHe/HimLet me enter

Specify Pronoun(s):

Email:

Date of birth:

Physical Address (street):

City:

State:

Country:

Zip Code:

Preferred phone:

Alternative phone:

Mailing Address:

Address:

City:

State:

Country:

Zip Code:

Will the client be the primary handler in public venues?

YesNo

If No, who will be?

Will the client be the primary trainer for the dog?

YesNo

If No, who will be?

Where did you hear about us:

If other, Please specify:

Applicant's Military/Veteran Status

Please provide the following information for the primary applicant. This is the individual with a disability that the dog will be assisting. Note: military/veteran status does not affect eligibility.

Military member or veteran?

YesNo

If Yes, complete the following

MIlitary dependent status (mark all that apply):

Not applicableSpouse is militaryFather is militaryMother is militaryOther

If your military dependent status is "other" please explain here.

Military Service:

Not applicableActive Service MemberVeteran

Branch:

Not applicableArmyAir ForceCoast GuardMarinesNavy

Last/current rank:

Upload your documentation(optional)

Veterans, active duty personnel, or their dependents wishing to take advantage of possible related funding sources should include a copy of DD Form 214 or an active duty ID card. This information is not required for the application and in no way impacts your acceptance as a client.

DD Form 214 or Active Duty ID Card

Disability Information

Please describe the applicant's disability and how it impacts daily life. To be protected by the ADA, one must have a disability, which is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.

Please confirm that you believe you have a qualifying disability per the ADA's definition above.

Yes

Please confirm that you understand a service dog is only protected under the ADA if it performs individually trained skills that directly mitigate the person's disability.

Yes

Type of service dog (or disability the dog will be mitigating). Atlas will determine the appropriate primary certification type based on your application and conversation with you. We certify the following types of assistance dogs. Please check all areas that you think might apply. Definitions of the types of tasks these dogs perform will be displayed as you check each box below.

Allergen alertHearing alertMobilityAutismMedical alertPyschiatricDiabetes alertMedical assistanceSeizure responseOther

If Other, Please specify:

Allergen Alert: Allergen alert dogs are medical alert assistance dogs specially trained to sniff out a particular substance (e.g., tree nuts, gluten, or shellfish) based on an individual’s allergies. Once the dog detects the allergy substance, they are trained to alert their handler, or someone nearby, to notify them of the presence of the scent.

Autism Alert: Autism alert dogs assist in calming and grounding an individual on the autism spectrum through tactile or deep pressure stimulation. They may also assist in teaching life skills, maintaining boundaries, finding a “runner” or alerting the parent if a child has left the area. Autism assistance dogs and sensory processing disorder dogs fall into the same category and usually perform identical tasks.

Diabetes Alert: Diabetes alert dogs alert their handler to dangerous or potentially deadly blood sugar highs and lows. Many dogs are trained to call 911 on a special K-9 Alert Phone if their partner cannot be roused. Diabetes alert dogs are also known as “blood sugar alert dogs” and fall in the general category of medical alert dogs.

Hearing Alert: Hearing alert dogs alert their deaf or partially deaf handler to specifically trained environmental sounds, including, but not limited to, alarms, doorbells, knocking, phones, cars, or their name.

Medical Alert: Medical alert dogs assist their handler with a medical disability through trained, specific, mitigating task work. Medical alert dogs differ from medical assistance dogs in that they are trained to alert to a specific medical condition the person is experiencing. Diabetes alert dogs and allergen alert dogs are both types of medical alert dogs. There are a number of conditions some dogs are able to innately recognize and will alert to on their own, such as seizures, migraines, or hypo-tension. Atlas classifies these as medical assistance dogs vs. alert dogs since we cannot ethically guarantee a dog will be able to alert, as the science behind what these dogs are detecting is not fully understood. Medical alert dogs, in addition, also typically perform all of the same tasks as medical assistance dogs.

Medical Assistance: Medical assistance dogs assist their handler with a medical disability through trained, specific, mitigating task work. This often includes alerting to times to take medications, bringing medication, alerting others if they need help, or assisting when when a person is dealing with symptoms of a medical condition such as traumatic brain injury or chronic pain. [Special Note: These dogs are not specifically trained to pre-alert or sense an episode before it happens. However, in many instances, the dogs will learn to pre-alert over time although the handler should not anticipate that this will happen in every case].

Mobility Support: Mobility support dogs work to provide bracing or counterbalancing to a partner who has balance issues due to a disability. Many mobility support dogs also retrieve, open/close doors or do other tasks to assist in day-to-day life or in an emergency. Dogs who assist people in wheelchairs or with other medical devices are also typically considered mobility support dogs.

Psychiatric Assistance: Psychiatric assistance dogs assist their handler with a psychiatric disability such as anxiety, depression or PTSD via specific, trained tasks. Tasks typically include interrupting anxiety, interrupting self-harm, alerting the person to others in their personal space or providing a physical buffer, waking from nightmares, applying physical therapeutic pressure, and helping the client ground and focus in stressful situations.

Seizure Response: Seizure response dogs respond to their handler’s seizures via trained tasks. The dog may retrieve medication, apply deep pressure stimulation to end a seizure early, fetch a nearby person to help or call 911. Other trained tasks are common as well.

Please explain the types of tasks you envision the dog doing to mitigate your disability, as well as any additional details you wish to provide.

Please confirm that you understand service dogs are not robots and can make mistakes. Dogs certified for allergen detection, diabetes alert or any of the other alert functions listed above are to be considered the equivalent of a backup medical device. They are not to take the place of the protocols recommended by your doctor.

Yes

Handler Information

Is there any handler other the client

YesNo

This information should be completed pertaining to the person who will be primarily handling the dog in public venues. The handler is the person(s) able to complete all training with the dog. It is not necessary to complete this section if the client and the handler are the same person.

First Name:

MI:

Last Name:

Pronoun(s):

They/ThemShe/HerHe/HimLet me enter

Specify Pronoun(s):

Date of birth:

Preferred phone:

Other phone:

Physical Address (street):

City:

State:

Zip Code:

Country:

Email:

Handler Mailing Address:

Address:

City:

State:

Country:

Zip Code:

Client Support and Needs

Who do you live with?

Are the other people living in your home supportive of you having a service dog in the home?

YesNo

If no, Please explain.

Is anyone in the home upset about having a dog in the home or frustrated with any behaviours of the dog?

YesNo

If Yes, who and what are their frustrations?

Explain the type of support you have within your home.

Explain the type of support you have available to come to your home.

Explain the type of support you have outside your home.

Please explain which of the above support systems you rely on for day‐to‐day life and which are there in times of emergency or illness.

Are you easily fatigued?

YesNo

If so how long does it take to recover?

Please describe how you mitigate/avoid fatigue.

Are there any medical devices or modifications to your home/equipment that you use in day-today life?

YesNo

If Yes, Please describe

Please describe your present medical support and treatment plan, including physical and mental health.

Is there anything else you wish us to know about your needs?

Please confirm that you understand and agree to the below policy:

Atlas does its best to minimize invasiveness and access to your personal information, and as such, does not require medical releases from our clients as standard practice. During your training and certification with Atlas, if we feel it is necessary for your personal safety or it is impacting the safety of your dog, we may ask you to include us in a conversation with the appropriate medical provider from your support team – social worker, counselor, doctor, etc. This will require you sign a release with your provider.

Yes

Client Lifestyle

Please explain a typical week in your life. Do you work, go to school, have regular hobbies or activities, etc.? Help us understand how much you are at home vs. out in different settings.

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Do you travel frequently?

YesNo

What are your common modes of transportation and frequency?

CarBusTrainPlaneOther

Do you or your household have frequent guests?

YesNo

Do they include children or other animals?

YesNo

Optional Comments:

Are there activities you would not want your dog to attend to?

YesNo

If so, which ones?

Are there activities you wish to do more of, either in the home or outside?

YesNo

If so, which ones?

Information about your dog

Note: If you are requesting certification for a second dog, please request and complete an Additional Dog form for the extra dog.

Name:

Breed:

Microchip number:

Date of birth( or closest approximation):

Gender

MaleFemale

How did you acquire the dog?

Are dogs, or your breed of dog, allowed in your home or under your homeowner/renter policy?

YesNo

If dogs, or your breed of dog, are usually not allowed, what is your arrangement with the property owner?

Where does your dog go to the bathroom?

How will you transport your dog for routine or emergency care?

Explain how you ensure your dog has their daily needs met for exercise, attention, training, and rest.

What is your back‐up plan to ensure your dog has the necessary short‐term care in the case you are not able to provide it due to illness, injury, or disability?

Will the dog ever be tied outside?

YesNo

If yes, please explain.

Where will the dog sleep at night?

What areas of the house will the dog have access to?

How many hours each day will the dog be alone?

Where will the dog go if applicant goes on vacation?

List the types, breeds, and ages of any other pets in the applicant’s home:

I understand that atlas reserves the right to notify humane animal control or law enforcement authorities if we feel your dog is in dangerous or abusive situation.

Yes

Veterinarian

Name:

Clinic/hospital name:

Address (street):

City:

State:

Country:

Zip Code:

Email:

Phone:

Training History

Do you have training history with dogs?

YesNo

Please tell us a little about your training history with your dog. This includes your time training on your own, as well as any time working with a professional trainer.

I have been regularly training with my dog since:

Please select one of the following

During that time, I believe I have spent at least 60 hours actively training my dog, either on my own or with a trainer. (Please note, over a one-year period, 60 hours would average to just over an hour per week.)

During that time, I estimate I spent approximately hours actively training my dog, either on my own or with a trainer.

We understand hours are approximate; we simply ask that they be representative of the time spent

Trainer

Are you currently working with a private trainer?

YesNo

If yes Please fill the section

Who on the team (if you have additional handlers other than the client) is primarily working with the trainer?

Trainer First Name:

MI:

Last Name:

Is your trainer an Atlas Certified Trainer?

YesNo

When did you begin working together?

How often do you currently meet with your trainer?

How often do you train/practice with your dog between sessions with your trainer?

Describe the training methods you and your trainer use when training your dog.

Describe the current training goals you are working on with your trainer.

How involved would you like your trainer to be once you start working with Atlas? (Please understand that Atlas has no control over their fees.)

Self-Training

Fill out this section if you have mainly been self-training (or using group training) but not working with a private trainer.

Who has primarily done the training of your dog to date?

Briefly describe your dog's level of training

Have you ever used the support of professional training (including puppy classes)?

YesNo

If Yes, Please describe the types and duration.

Additional Training Questions

Please Answer for the primary person who will be training for the dog.

What have been your primary source(s) of dog training knowledge?

What has been your history with dogs during your life?

What training methods do you prefer to use with your dog?

What do you like to do to let them know they did what you want?

What do you like to do if they do something you don't want?

Have you started working on disability skills with your dog?

YesNo

If Yes, Please explain

Have you started working on public access with your dog?

YesNo

If Yes, Please explain

What has been your biggest training barrier in training and caring for your dog so far?

Physically:

Emotionally:

Additional background information

Has the applicant or guardian ever surrendered, sold, or transferred ownership of a pet?

YesNo

If yes, please explain below

List any reasons why the applicant, handler, guardian, or household member would ever surrender, sell, or transfer ownership of a pet.

Has the applicant, secondary applicant, handler, guardian, or household member ever been convicted of a crime?

YesNo

If yes, please explain. Please note: Convictions do not necessarily prevent eligibility.

Does the applicant, guardian, or household member have pending criminal charges?

YesNo

If yes, please explain.

Emergency Contact Information

Primary Contact

First Name:

MI:

Last Name:

Address:

City:

State:

Zip Code:

Country:

Email:

Preferred phone:

Alternative phone:

Relationship to client:

Secondary Contact

First Name:

MI:

Last Name:

Address:

City:

State:

Zip Code:

Country:

Email:

Home phone:

Mobile phone:

Other phone:

Relationship to client:

Additional Comments

Please use the space below to provide any additional information you would like to know about your dog.

Information on the person completing this form

This form was completed by

Applicant/ClientHandlerOther

Relationship to the client:

Does the applicant know that you are submitting this application on their behalf?

YesNo

First Name:

MI:

Last Name:

Address:

City:

State:

Zip Code:

Country:

Email:

Preferred phone:

Alternative phone:

Submitting the Application

Upload your Supporting Documents

As a reminder, these forms can be found on the first page of this application.

Letter of Medical Indication:

Veterinary Health Form:

Any Additional Documentation:

All set? Please do a final review of your application and this document. We look forward to receiving your application.

icon of checklist Our Application Readiness Checklist to ensure you and your dog are ready to apply.

We will review the application and other required forms for completeness. If information is missing, we will communicate with you to help resolve the issue. When all information is provided and any issues are resolved, we will set up a time to speak with you via video conference.

I have read and understand the processes outlined in the Atlas Certified Team Program document including but not limited to, expectations of training involvement, scope of training supported, allowed training methods, cost and timeframe for certification. All information is complete and accurate to the best of my knowledge.

Yes

I commit to using only positive, ethical training methods with my dog.

Yes

I understand that training my own dog to be a service dog is a big commitment and am ready to put in the effort necessary so for the duration of the program, which is at least 6 months. I also understand my dog will need regular maintenance training and care their entire life, and am committed to do so.

Yes

I understand this application does not guarantee I will be accepted as a client and acceptance as a client does not guarantee my dog and I will be certified as a team.

Yes

In the case where handlers in addition to clients are involved, I understand everyone must be committed to and involved in the training, and each handler will undergo the final certification test as well as required recertification tests.

Yes

Client Name:

Date:

Primary Handler or Guardian's Name(If client is under 18 or if dog is primarily handled by another adult). Guardian should be the one signing and is agrees all answers in this application are accurate:

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