Service Dog Application

By submitting this application for one of our service dogs, you are consenting that a JLAD representative initiate direct communication with your physician and/or mental health provider regarding your needs for an assistance dog.

JLAD will keep your entire application confidential. Your pictures and written application will become the property of The Joys of Living Assistance Dogs.

Please review the application instructions before completing this form.

Your application will be reviewed, and an interview scheduled when all information has been received.

Part A - Client Application, completed by client

Part B - Photo Outline

Part C - Medical Information

Part D - Financial Plan for the dog

This application must be IN THE WORDS OF THE PERSON WHO WILL USE THE DOG.
If this form is completed by someone other than the applicant, please provide the following information.

Name of Transcriber

Relationship

Check all that apply:

I'm a civilianI'm a Veteran/First ResponderI'm applying for a JLAD mobility dog.I'm applying for a JLAD PTSD dog.I'm applying for the Owner Trained Mobility Program.I'm applying for the Owner Trained PTSD Program.

Military Personnel Only

Do you have military affiliation?

What branch?

Are you active or retired?

For non-active military clients, please attach a copy of your DD214 form to this application.

Part A: General Information

Most JLAD dogs assist people with primary mobility impairment, such as multiple sclerosis, muscular dystrophy, cerebral palsy, spina bifida, paraplegia, tetraplegia, arthritis, amputation, stroke, or traumatic brain or spinal cord injury. JLAD does not train dogs to assist individuals with seizure disorders, blood sugar disorders or those with significant vision loss.

Date of Birth

MM/DD/YYYY

Age

Height

Weight

Gender

MaleFemaleOther

Legal First Name

MI

Last Name

Personal Phone Number

Personal Email

Work Phone Number

Employer

Address Line 1

Address Line 2

City

Country

State

Provinces

State/Province

Postal Code

Nearest Relative

Relationship

Relative's Personal Phone Number

Relative's Work Phone

Address of Relative

Address Line 2

City

Country

State

Provinces

State/Province

Postal Code

What is your disability?

How long have you been disabled?

Do you have any other diagnosis, including mental health diagnosis?

If disability was caused by injury, what progress has been made post injury?

Please indicate the modes of transportation that you use:

I driveBusCabOther

Other modes of transportation

What work, school, or rehabilitation program(s) have you completed?

What is your current work or school schedule?

What are your plans for work or school?

List the people living in your home, including their ages and their relationship to you

Do any other members of your household have a physical or mental disability?

YesNo

If yes, how are they disabled and what are their limitations?

Please describe your home and yard.

Is your yard fenced?

YesNo

How high is your fence?

If your yard is not fenced, or if your fence is too short or needs repair, will you be able to put up a secure fenced area before you receive your dog?

YesNo

Do you currently have pets?

YesNo

What pets do you have now? Describe type and age.

Veterinarian's Name and Phone

Name

Phone

If you have a dog now, would you be willing to give up your present dog if it cannot get along with a JLAD dog?

Yes (or does not apply)No

If your present dog is not well-mannered, are you willing to train your dog before you receive your JLAD dog?

Yes (or does not apply)No

What dogs have you had before? Describe what kind and how old you were.

Have you ever re-homed a pet? If so, what was the reason?

What are your expectations of the JLAD dog?

On a daily basis, how will you handle walking, cleaning up after, feeding, medicating, exercising, grooming, and medical care for your JLAD dog?

How will you handle the care of your JLAD dog if you are hospitalized?

Will it be difficult for you?

To attend placement classes at the JLAD Training Center in Salem, Oregon for five hours a day for 2 weeks?

YesNo

To limit your calendar for the 30-day bonding period?

YesNo

Please explain any Yes answer.

Part B: Photo Outline

Your pictures are critical. JLAD reviews it frequently during the placement process.

a. Initially, to see IF we can train a dog for your needs and accept you as a client.

b. When matching teams, to evaluate whether a dog in training fits your lifestyle and your needs.

c. During custom-training of the dog to meet your needs

*Images must be smaller than 3MB and of type .bmp, .gif, .jpg, .jpeg, .png, .tif, or .qtf

Self

Full-body

Show your environment

Home - Please provide six to ten photos of the interior and exterior of your home and yard (including any fencing)

Pets - Any present pets you may have

Family Members

Other - Pictures of your work, school, recreational and/or social environment that may be helpful

Application Part C -

By submitting Part C of this application to your provider, you are giving consent for JLAD to contact your provider to obtain further information that directly pertain to your application for one of our service dogs. Please contact your physician/mental health provider(s) and give them permission to release your medical information to JLAD.

Then, copy and forward the blue electronic link posted below to your provider(s), for them to complete and return to JLAD.

It is imperative that your provider use the exact Legal First Name and Last Name as you have used on this application. If perchance they miss a hyphen or misspell your name this information will not be linked to your application and we will not be notified as having received it!

https://www.tfaforms.com/4911517