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Page 1

Facility Service Dog Pre-Qualification Form

Facility Name

Applicant Information (Facility Dog Handler)

First Name

Last Name

Personal Email Address

Are you able to afford the costs of caring for a facility dog to include food, equipment, supplies and veterinary care for the lifetime of the service dog, an average of $50-$200/month?

Yes

Are you able to travel for 10 days in order to participate in a classroom/group setting for Team Training?

Yes

GDA|TLC uses only positive reinforcement training methods. A facility dog’s training must be maintained by the handler. If selected, are you willing to use only positive reinforcement training methods and actively participate in the dog’s ongoing training, annual assessments and health checks for the working life of the dog?

Yes

List all household members. Include ages and relation.

Lead ID

Lead ID Populated?

Are you or another household member allergic to dogs? (There are currently no hypoallergenic dogs in the service dog program. We encourage you to explore AssistanceDogsInternational.org to find other programs that can meet your needs.)

YesNo

Page 2

Applicant Contact Information

Phone

Country

Address Line 1

Address Line 2

City

State

Province

ZIP / Postal Code

Facility Contact Information

Facility Decision Maker's Name

Facility Decision Maker's Phone

Country

Address Line 1

Address Line 2

City

State

Province

ZIP / Postal Code

Page 3

Facility Information

Please describe the population served by the facility.

Job title and description of your role.

Please describe how you envision a facility dog will help the population of individuals served by the facility. Include if the facility dog will also be working in environments outside of the facility.

Are there other dogs in the facility?

Yes

If yes, please describe each dog’s role in the facility.

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