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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!

Thank you for your interest in Atlas Assistance Dogs’ Team Certification Program. We are excited to learn a little more about you to determine if our program may be a good fit.

Before receiving Atlas’ full application, please fill out this pre-application to ensure you and your dog would be successful in our program. Please also ensure you have fully reviewed Atlas’ Client Team Certification program description, as well as our Obedience and Temperament Checklist

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 pre-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.

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

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

I acknowledge I have read the client program and feel my dog and I can be successful and are committed to the work necessary.

Yes

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

I acknowledge I have read the obedience checklist and feel my dog has the necessary behavior and skills to meet the program requirements.

Yes

If we determine that you meet our initial criteria, we will send you our full application. At that time, you will need to:

Provide a copy of results from an AKC Canine Good Citizen (CGC) test your dog passed within the last year (please let us know if this is a significant barrier; we can look at options for you to complete this prior to submitting your final application)
Provide a Letter of Medical Indication from your provider attesting to your needs and that a dog would help mitigate your disability
Provide a completed Atlas Veterinary Health form
Upload two to three videos demonstrating some of your dog's skills

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

Once we receive your pre-application, we will contact you in approximately one week via email.

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.

Contact Information

First Name:

MI:

Last Name:

Suffix:

Phone (Preferred):

Phone (Secondary):

Email(Non-Atlas):

Date of Birth:

Pronoun(s)

They/ThemShe/HerHe/HimPrefer to self-describePrefer not to answer

Specified Pronoun(s)

Primary Language:

Other languages (select any for which you have conversational and/or written ability)

Street Address

City

Country

State

Provinces

State/Province

Postal Code

Is there any additional handler(s) other than the client?

YesNo

Additional Handler(s)

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

Last Name

Phone

Address Line 1

City

Country

State

Provinces

State/Province

Postal Code

Demographic Information

Atlas respectfully requests you complete this form. We secure this data carefully and respect your privacy. Please note, demographic data never impacts if you are accepted for a given program.

Most items are multi-select. Please choose those you feel you best relate to. You may also choose to self-describe or to select you prefer not to answer.

Gender Identity

Specified Gender Identity

Sexual Orientation

Specified Sexual Orientation

Race/Ethnicity

Specified Race/Ethnicity

Veteran Status

Specified Veteran Status

Ability Status

Specified Ability Status

Ability Accommodation

Specified Ability Accommodation

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 for our program. It may impact eligibly for scholarship funds to offset program costs.

Military member or veteran?

YesNo

If Yes, complete the following

Military dependent status (mark all that apply):

Not applicableSpouse is militaryFather is militaryMother is militaryLet me enter

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

Financial Situation

Atlas does all it can to make our programs affordable and accessible to all who would benefit from a service dog. We recognize for some, an overall program fee of $700 may be more than is affordable. For others, they may be able to afford more which can help us offset cost for others. Need for assistance or ability to provide funds to support others does NOT impact your acceptance as a client.

I request financial assistance

YesNo

Atlas does not always have scholarship funds available; we will do our best to support you. Please specify the amount of assistance requested.

Max possible discount availableTraining fee fully covered (discounted to $250)Training fee subsidized (discounted to $450)Other

Please specify what you feel you are able to pay for the program.

Please explain your situation and anything you would like us to consider regarding providing financial assistance.

I would like to add a tax deductible donation toward funds to offset client program costs for others. 100% of these funds will go to support clients who need financial support to pay for our training and certification program.

YesNo

Thank you! Please make a tax deductible donation in the amount of your choice here. Please be sure to specify in the dedication field that it is to be used to offset client certification costs. Please understand donation does not ensure acceptance in our program. Acceptance is purely based on whether we feel you and your dog can be successful and we have availability in your area. Thank you for helping ensure anyone who would benefit from an assistance dog can have one!

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 alertPsychiatricDiabetes 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 that 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.

Do you use any adaptive equipment or modifications? Please list what type of equipment you use, where, and how often? (e.g: Manual wheelchair full time daily in and out of the home, Cane as needed outside of the home)

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

Client Support

Who do you live with? Please list relationship to you and age.

Are all the 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 and outside your home (e.g: help with running errands, care of the dog, emotional support etc.)

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

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):

How long have you had the dog?

Gender

MaleFemale

How did you acquire the dog?

Training Background

Please tell us a little about your training history with your dog. Including working with trainers, group classes, training on your own etc.

Who has been the primary trainer for your dog?

How much time on average do you typically spend training your dog per week?

Please describe your dog's current level of training.

What environments has your dog been exposed to?

Home onlyParksDog parksQuiet neighborhoodsCity/busy neighborhoodsPet storesGroomerCar ridesPet friendly stores (home depot, Lowes etc.)Service dog only placesOther

Please list the types of environments your dog has been exposed to

What have been some challenges that you have encountered while having and/or training your dog?

Describe your dog's response when they are allowed to interact with other dogs. Be sure to include off leash and on leash.

What is their response if a strange dog runs up to them unexpectedly? What have you found successful or needed to help them when interacting with other dogs?

Describe their comfort level in meeting new people. Are they calm? Fearful? Excitable? etc. Are there certain types/ages of people they seem to have issues with? What have you found successful or needed to help them?

How do you currently prefer to have your dog greet strangers?

Can you describe your understanding of positive training methods?

Do you currently, or have you ever used any prong, vibration, or e-collars?

YesNo

Please describe which of these tools you use or have used. Are you willing to work towards fully removing these types of collars from your dog? If not, why?

Have you begun working on any disability skills?

YesNo

Please describe what type of disability skills you have started to work on and where you are at in the training.

Have you begun working on public access skills?

YesNo

Please describe the type of training you have been doing in public.

Have you passed an AKC Canine Good Citizen (CGC) test with your dog in the last year? If not, will you be able to pass one prior to submitting the full application? Let us know if you need help finding an assessor.

I have passed a CGC in the last yearI am planning on passing a CGC prior to submitting my full application for certificationPlease help me find an assessor (please ensure you have tried to find an assessor on your own before checking this box)

Trainer

Are you currently working with a private trainer?

YesNo

If yes, please fill out this section

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

Trainer First Name

Trainer Last Name

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.)

Additional Comments

Please use the space below to provide any additional information you would like to know about you or 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:

Last Name:

Email:

Preferred phone:

Submitting the Application

Acknowledgements

Please carefully read the following statements.

I understand that I must pass my Canine Good Citizen Test and upload proof to submit a complete application for Atlas' Certification Program.

Yes

I understand that this is a pre-application and does not guarantee that I will be accepted to move to the next step of the application process.

Yes

I understand that the full application will involve submitting a Letter of Medical Indication, a veterinary health form, my CGC results, and 2-3 short videos demonstrating how my dog responds in certain settings. Please see review this video description.

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

All information provided in this application is complete and accurate to the best of my knowledge.

Yes

All set? Please do a final review of your pre-application.

If you wish, you can download the forms that you will be needing to submit with your full application below as well as information about the video submission and CGC test.

icon for letter of medical indication Letter of Medical Indication Template

icon for vet health letter Veterinary Health Form

icon of video Instructions for Video Submissions

Canine Good Citizen Information

We will review the pre-application and other required forms for completeness. If information is missing, we will communicate with you to help resolve the issue. Your pre-application will help us determine if you might be a good fit for our program. If so, we will send you our full application for you to submit. If we feel that you may not be ready for our program, we will try to provide additional resources for you.

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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Contact Information