Canine Angels Dog Questionnaire

Canine Angels Dog Questionnaire
Canine Angels Service Teams

13475 N. Applegate Rd.Grants Pass, OR. 97527 888 K9 ANGLS or 541 846-6400 www.Canine-Angels.org email: info@Canine-Angels.org
Mother's Name

First Name Last Name
Father's Name

First Name Last Name
Child's Name

First Name Last Name
Child's Age
Child's Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Please describe your child's disability(ies)
Is the disability progressive?

Yes No
Does the applicant use:

Manual wheelchair Electric wheelchair Braces Crutches
Is the applicant's mental development at an average level?

Yes No
Comprehension and ability to follow directions ok?

Yes No
Working at what age level?
How is the applicant's speech?
Do parents live together?

Yes No
Mother's occupation
Please specify
Father's occupation
Please specify
Activity level (away from home)
What's a typical day life for the applicant and family?
Please list names and relationship of all people living in your home and ages of minors:
Has the applicant been exposed to dogs?

Yes No
Was the interaction positive?

Yes No
Any fear of certain kinds of dogs?

Yes No
If yes, please explain.
Has the applicant family ever had a dog before?

Yes No
Is anyone in the household allergic to dogs?

Yes No
Please tell us about any pets in the home (breed, age, gender)?
Whose idea was it to get an assistance dog?
How do you think your child will benefit from having an assistance dog?
What specific tasks would applicant/family like their dog to perform?
Do all family members agree on the decision to apply for an assistance dog?

Yes No
If no, please explain.
Has the family considered the extra costs of having a dog, including quality food, dog supplies, and preventative care such as shots, heartworm and flea medication, and teeth cleaning?

Yes No
Has the family considered the extra time for training, grooming, and exercise, plus poop patrol? The dog must be picked up after 100% of the time…no exceptions.

Yes No
Is the family aware of the $50 application processing fee and Team Training class fee ($2,500 for Pal and Facility Dogs, $3,500 for Service Dogs)? (dog is provided free of charge and Canine Angels can offer advice and assistance for fundraising)

Yes No
Is the family aware that Team Training is located in Grants Pass, Oregon, and that travel, lodging, field trips, and some meals are the responsibility of the applicant family?

Yes No
Is there anything else that Canine Angels should know?
How did you find out about us?
Should be Empty:

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Canine Angels Dog Questionnaire

Canine Angels Service Teams