Owner Trained Service Dog Application Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact: Name * First Name Last Name Phone * (###) ### #### Email * Medical History: This is kept confidential by TFCA. Date Of Birth * MM DD YYYY Weight (lbs) * Height (feet) * What is your primary disability? When were you diagnosed? * Are there any other significant disabilities? Please describe: At what age were you diagnosed? * Is your disability progressive? * Are you currently under a management plan recommended by your medical team? Please explain * Check all that apply: * Speech Impairment Vision Impairment Reduced Stamina Spasticity Hearing Loss or Impairment Lack of Coordination Memory Loss Muscular Weakness Limited Mobility Heat/Cold Sensitivity Seizures Skin Sensitivity Fainting or Pre-syncope Anxiety Attacks Dissociation Depression Heightened Emotions Self Mutilation Additional Symptoms: * Do you have any significant allergies? Please Explain * Do You: (check all that apply) * Drive Fly in Airplanes Ride Buses Driven by others Description of the dog you would like to owner train: Name * Breed: * Age: * Gender: Are they Fixed? * Have they been Temperament Tested? * Do they have any prior training? Please explain. * Has your Dog shown any aggressive tendencies or concerning behaviors toward people or other animals? * Do you have an effective support system that could provide for your dog, should you be unable to do so? Please describe: * What task(s) do you envision your dog performing for you? * After Submission, please allow 2-3 business days in order for us to review it. If approved, we will send an email in order to schedule your complimentary interview. You will need to consistently check your inbox. If we do not hear a response within 1 week, your original application will be forfeited. Serious inquiries only, we value your time and value ours. There are additional documents that will be required to be signed in order to finalize. Thank you!
