Right now we do have a waiting list. Time on our waiting list does vary because of the type of worked the age of the dog. To speed things up you can down load this form and get the ball rolling.
Debbie
Smokey's Assistance Dogs Foundation greatly appreciates your completing this form. We invest over $10,000.00 and between 6 to 18 months in training each Service Dog. Your information is essential for an accurate evaluation of your applicant. We are unable to process applications that are not complete.
Name: ______________________________
Address: ________ City: _______ Province: _____ Postal Code: _________
Tel: ( ) _______ Fax: ( ) _______ E-Mail: __________
Sex: ___ Date of birth: _______
Height: _____Weight: ____ Occupation: _______________________
How did you here about Smokey's Assistance Dogs Foundation?
Name of contact person (relative or friend) in case we are unable to reach you:
Name: ___________________________________
Relationship: _______________
Address: ___________________________
Tel.: ( ) _______ Fax: ( ) ____________
Name of primary physician: _______
Address: ________________________
Tel.: ( ) _______ Fax: ( ) ____________
How long have you been this doctor�s patient?
Name of specialist (if applicable): _____________
Specialty: ___________________
Address: ______________________________
Tel.: ( ) _______ Fax: ( ) ___________
Please list others, if any, on reverse.
HOUSEHOLD
What are your current living arrangements?
living independently
Group housing
Institution
Please complete this section if you live with others:
NAME
AGE
RELATIONSHIP
OCCUPATION
ALLERGIES
DISABILITIES
EXPERIENCE WITH DOGS
How many hours per day of attendant/family care do you use?
How many visits per day?
HOME SETTING:
Type of home:
If an apartment, what floor?
Do you have a fenced yard?
If not already fenced, would you be able to fence an area?
If you were unable to provide a fenced area, how would you accommodate the dog�s toileting and exercise needs
Do you live in an surban, or rural area?
Are the streets around you're home paved or gravel?
Are there sidewalks?
Do you currently own a dog? _______ Age ____ Breed ____
Any other pets? Have you owned dogs in the past?
A service dog?_________________
SCHOOL/EMPLOYMENT ENVIRONMENT:
Are you currently attending, or planning to attend, school (college, university)?
Full time _____Part time _______Hours: _______
What grade/year: ______
Type: (high school, college, etc�)
Name of school: ________________________
Address: _________________________
Name of employer (if applicable):
Occupation _______Full time ___Part time ___ Hours:__
Describe the setting (downtown, high rise, shopping mall, etc.)
Will the dog be going to work/school with you? _____
Is there anything at your workplace/school, which might pose a hazard to your dog�s health or well-being?
(loud machinery, vehicles toxic vapors or fluids, dangerous machinery, slippery or littered floors, high frequency noise etc.)
Please name and describe: ____________
LIFESTYLE:
How would you describe your activity level?
Please list your hobbies and interests:
Please list any volunteer work:
Based on your personal lifestyle, how many hours per day will the dog be left alone?
Do you have your own vehicle?
If yes, please describe (side-lift van, etc.):
Do you use public transit?
Describe your physical/medical disability:
Cause:
How long have you been disabled?
Prognosis:_________ Level of Hearing Normal _______
Impaired__________ Level of Vision Normal __
Impaired __________ Quality of speech (level/tone): ___________
Please rate the following with G-Good F-Fair P-Poor
STRENGTH STAMINA RANGE OF MOTION
Upper body
Right leg
Left leg
Right arm
Left hand
Do you have any problems with:
Allergies (specify) Balance Brittle Bones
Chronic Pain Cold Sensitivity Depression
Heat Sensitivity Memory Loss Pain Sensitivity
Reaction Time Seizure Skin Sensitivity
Spasticity Other (please specify):
Do you use Assistive devices?
If yes, please list
Do you use a wheelchair? manual or electric)
Controls: right left
Weight of chair:
Type of battery:
Do you have an Emergency Call System/Lifeline: yes
Other (specify):
List all medications, both prescription and non-prescription, that you are presently taking:
DRUG PRESCRIBED?
DOSAGE
HOW OFTEN?
DAILY AS NEEDED
I have completed the above application with the correct information I understand that any false information may delay and/or cancel my application to Smokey's Assistance Dogs Foundation
_____________________ ___________________
APPLICANT'S SIGNATURE DATE
______________________________ ____________________
SIGNATURE OF PARENT/LEGAL GUARDIAN DATE
_______________________ ________________________
OR POWER OF ATTORNEY DATE
L = LOW
M= MODERATE
H= HIGH
E= ESSENTIAL
RATE SKILLS IN ORDER OF IMPORTANCE TO YOU
Fetching dropped items
Fetching named items
Opening/closing interior doors
Turning on/off switches
Assisting with undressing
Assisting with transfers (steadying)
Assisting with getting in and out of bed or rolling over in bed
Going for help/alerting another person to seizures
Operating a lifeline/call attendant
Other (please list below)
Addresses of two people, not relatives and your current veterinarian (if applicable), whom we can contact for character references. This information must be complete in order to pursue your request for a Service Dog.
Please print this information.
Name: ________________________________
Address: _______ City: _________ Province: _____ Postal Code: _____
Tel.: ( ) _______ Fax: ( ) ____________
Name: ___________________________
Address: ___________ City: ______ Province: _____Postal Code: _______
Tel.: ( ) _______ Fax:( ) ____________
Veterinarian: _______________________________
Address:_______ City: _________ Postal Code: _______
Tel.: ( ) _______ Fax: ( ) ____________
PLEASE READ CAREFULLY BEFORE SIGNING
There are legal, moral, and financial obligations involved with having a Service/Assistance Dogs.
Service/Assistance Dogs teams are ambassadors who, through their actions, allow people to accept and welcome the presence of Service/Assistance Dogs in public places.
Your Service/Assistance Dogs, as your partner and extension of your being, must work well, be well-behaved, well groomed and health Service/ Assistance Dogs are very special canines but they are still dogs.
They must be cared for daily.
They require relief several times daily in all kinds of weather and these reliefs areas must be cleaned immediately.
They require time and effort daily for food and water, warmth, grooming, obedience training, skill training play, and work Service/Assistance Dogs incur expenses, e.g. feeding, annual vaccinations, and Medical tests as advised, and twice yearly check-ups by a veterinarian.
Veterinarian visits could be more often should a condition or illness warrants a professional.
Check with a veterinary clinic in your area to determine costs and expenses you can expect for routine and emergency visits Service/ assistance Dogs require a commitment in return for all the wonderful, new and exciting experiences that you will experience as a team.
Service/Assistance Dogs require basic respect, praise for a job well done, discipline, love, and creature comforts to be well adjusted, loyal, responsible, willing and healthy to lead you to untold freedom and independence
From the time that we receive your application, all information will be kept confidential.
As the applicant, you should understand that due to limited resources Smokey's Assistance Dogs Foundation will prioritize applicants and acceptance will be based on a review by the Smokey's Assistance Dogs Foundation Application Committee.
If in our assessment any of the information supplied on the application inaccurately represents your ability to care for and use the services of a Service/Assistance Dogs Smokey's Assistance Dogs Foundation has the absolute discretion to cancel this agreement and any future agreements
You are further advised that if accepted into the program, the training may be terminated at any point if it is felt that it affects the health and safety of the applicant.
You are further advised that Smokey's Assistance Dogs Foundation assumes no liability in case of accident during the training program, upon graduation or during the time, you are a working Service/Assistance Dogs team.
During your stay in residence at the training center, the student and the Service/Assistance Dogs train together and begin to establish the bond that is necessary for a team to succeed.
A good year of adjustment can be expected before the client and Service/ assistance Dogs work together as a team.
Mandatory follow-up contact and communication between the client and Smokey's Assistance Dogs Foundation training staff are maintained to ensure ongoing success Service/Assistance Dogs and obedience training must be maintained throughout the dog's working career
All family members must obey instructions given by the trainer as to their contact with the Service/Assistance Dogs and its management.
Failure to follow instructions may result in the dog being returned to the training center
It must be understood that a Service/Assistance Dogs is a working dog, not a pet.
Children and other people are not to interfere when the dog is in harness.
Our dogs are not trained to be guard dogs or attack dogs A Service/ Assistance Dogs is a valuable, trained dog and is not allowed to run loose.
The dog must always be on leash
Having a Service/Assistance Dogs is a legal, moral and financial commitment for the life of the dog, about 10-12 years.
Careful consideration must be given before accepting the responsibilities of a Service/Assistance Dogs
Smokey's Assistance Dogs Foundation remains the legal owner of the Service/Assistance Dogs.
If proper procedure is not followed, Smokey's Assistance Dogs Foundation has the right to remove the dog.
I have read, understand and agree to the above.
_______________________ ______________
Applicant's Signature Date
____________________ _______________________
Applicant's Name Date
_______________________ ________________________
Witnessed By Date
CHECKLIST
Have you included the following information with your completed and signed application?
1. Medication examination report from your physician
2. Reports from Occupational and/or Physiotherapists
3. Character references (2)
4. Map to your home
5. Recent Picture of yourself.
6. Video of your home, yard, work place or school.
FAILURE TO INCLUDE THE ABOVE INFORMATION WILL RESULT IN A DELAY IN PROCESSING YOUR APPLICATION FOR SERVICE DOG.
RETURN THE APPLICATION TO:
Smokey's Assistance Dogs Foundation
12607 73 Street Edmonton, AB T5C 0S7 Canada
Phone780-457-0927
Email: [email protected]
Smokey's Assistance Dogs Foundation
MEDICAL INFORMATION
To be completed by physician Please print or type
Date
Applicant's name
Please release to Smokey's Assistance Dogs Foundation information regarding my health. This information will only be used to evaluate my situation in making a successful canine placement and will be respected by as confidential medical information
_____________________ ____________
APPLICANT'S SIGNATURE DATE
___________________________________ _________________
*SIGNATURE OF PARENT/LEGAL GUARDIAN DATE
____________________________ ________________
*POWER Of ATTORNEY DATE
(* please also forward any documents when power of attorney or legal guardian are involved*)
Physician's name: ___________________________
Physician's Specialty:______________________________
Address:____________ City: ________Province:_____ Postal Code:________
Telephone:____________ Fax: _____________
MEDICAL Information
Diagnosis of patient's disability. (Continue on reverse if necessary)
Primary __________________________________________
Describe disability ________________________________
Secondary _________________________
Describe disability ____________________________
Explain limitations and additional pertinent information
Are two or more limbs impaired___________
Explain ______________________
Prognosis and effect of the condition on the individuals ability to perform
Activities of Daily Living (ADL)
Please list all medications currently being taken by your patient
MEDICATION
DOSAGE
CONDITION OR ILLNESS
SIDE EFFECTS
EXPERIENCED BY YOUR PATIENT SELF ADMINISTERED (YES OR NO)
Is your patient affected by any of the following
Heart disease Cancer High blood pressure
Rheumatic fever Diabetes Infantile paralysis
Impaired hearing Nervous disorders impaired sight
stroke Convulsive seizures
Epilepsy Fainting spells Allergies
Polio Limited mobility Memory loss
Asthma Coordination problems Reduced stamina
Spasticity Muscular weakness chronic pain
Depression Skin sensitivity Brittle bones
Imbalance Speech impediment Does your patient
1=LOW, 10=HIGH
Exercise judgment and make decisions necessary for ADL?
Have sufficient perception and memory to sustain ADL?
Have the ability to follow directions to learn necessary ADL?
Have the ability to make decisions for own or other's needs and safety?
Comments:
PHYSICIAN'S SIGNATURE DATE
AUTHORIZATION FOR RELEASE OF INFORMATION
(to be given to your medical professionals) ______________ADDRESS: __________________ I, _______________have applied to Smokey's Assistance Dogs Foundation for training with, and the receipt of, a Service Dog. In order to fully assess my suitability for the myself between Smokey's Assistance Dogs Foundation and ________________I understand that Smokey's Assistance Dogs Foundation will keep all information in strict confidence and that this information will be used only to assess my suitability for training with, and the receipt of, Smokey's Assistance Dogs Foundation
____________________ _____________
Signature Date
______________________ _______________
Witness Date
This letter acknowledges that I am aware of the fact that __________ intends to apply for the services of a Service By signing this form, I am expressing MY/OUR agreement to the dog being (working and/or living) on the premises and I am fully aware that it will be used as a working dog only.
Name
Please print or type Signature
Please indicate whether landlord or employer:
Company Name:_______________________________
This letter acknowledges that I am aware of the fact that __________ intends to apply for the services of a Service Dog By signing this form, I am expressing MY/OUR agreement to the dog being (working and/or living) on the premises and I am fully aware that it will be used as a working dog only.
Name
Please print or type Signature
Please indicate whether landlord or employer:
Company Name:________________________
Address:_______________________________
Date: ____________
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Copyrights 2000
Smokey's Assistance Dogs Foundation
All Rights Reserved
Revised: June 26, 2005