Autism Support Dog Application

Child Details

Application Type *

Salutation *

First Name *

Surname *

Identity Type *

ID Number *

Gender*

Birthdate *

Interest In Guide Dogs *

Contact Person*

Primary Person Contact Details

First Name *

Surname *

ID Number *

Gender *

Phone Number *

Email Address*

Address Information

Residence *

Property *

Home Address *

Postal Address *

City *

Province *

Do you plan to move soon?*

Do you live near an open space where dogs are allowed?*

Do you rent, own or live in a family- owned property*

If any of your family member is allergic to or afraid of dogs, how do you plan to address this?*

Have you owned a dog before? *

Are these pets socialized with dogs?*

Are members of your household supportive of your application?*

Would you be able to attend the training to learn about dog care, handling and behavioural issues?*

Are you able to provide time to maintain the work standard of the dog?*

Where would your dog be when you are out (if not at school with the child)?*

How do you generally travel? *

If left alone, how many hours per day would the dog be left alone?*

Parent/Guardian information

Parent/Guardian occupation *

Parent/Guardian Employer *

Parent/Guardian Work address *

Parent/Guardian Work telephone *

Parent/Guardian what days/hours per week do you work? *

Parent/Guardian has permission for an Autism Support Dog been obtained? *

Parent/Guardian Describe the facilities available for the dog at your work place/Office/Factory, etc. *

Other Information

Include any secondary diagnosis *

How much assistance does your child need *

Does the applicant regularly reside in another household? *

How did you hear about Autism Support Dogs?*

Autism Diagnosis *

Level of autism: please explain *

How does their secondary diagnosis affect the childs skills of daily living, are there any limitations?*

Medical information

Primary doctor*

Primary doctor address*

Primary doctor contact details*

List of all medications your child takes and the frequency*

Is there an appropriate relief area for the dog?*

Information about the child

Your child is *

Is your child able to give verbal cues t *

Your child’s activity level is: *

How has autism impacted the family?*

Describe your child’s typical day (morning routine, school, evening and transportation requirements)*

Describe how you see an autism Support Dog helping your child’s daily routine?*

Is there specific service you would like the dog to perform that would possibly impact your child’s life?*

What are your primary concerns about your child’s current level of functioning? (Escapes, frequent tantrums, tendency to wander aggression and sleeping problems)*

School Information

Name of School*

School Address*

Type of School*

School Phone No*

Mobility Information

What is your child’s normal walking speed?*

Does your child refuse to walk?*

Does your child bolt/run off?*

Describe your and your child’s gait/posture*

What degree of activity can you/your child sustain? (I.e. stamina level)*

Health Information

Weight *

Height *

Do you have any degree of hearing impairment*

If YES, please describe*

Do you have any degree of visual impairment*

If YES, please describe*

Are you diabetic?*

If YES, please describe*

Are you on any medication and if so plaase*

If YES, please describe*

Do you attend regular doctor/hospital appoinments?*

If YES, please describe*

Do you or any family members have epilepsy, allergies, or any seizures/blackouts?*

If YES, please describe*

Other Enviroments

Where will you take the dog? *

Places with children /other animals*

Please describe*

Place of Worship*

Do you drive?*

Type of transport *

What hobbies or activities do you have pay day?*

Costs Information

During training, the cost of the dog, accommodation and all equipment is R205.00. Is this affordable?*

The cost to maintain a guide dog is approximately R950.00 to R1000.00 a month. Can you afford this?*

Plus, a once-off payment of R100.00 (One Hundred Rand) for your assistant?s board and lodging?*

You are required to join a pet insurance *

General Information

What prompted your application?*

Routine Information

What time do you/your child get up in the morning?*

Describe your child’s normal routine first thing in the morning?*

Describe your/your child’s normal routine in an evening (what time is bed time?)*

In a normal week (Monday to Friday) what sort of things/activities do you/your child and family participate in?*

What activities do you/your child take part in at weekends?*

What are your child’s favourite pastimes/hobbies?*

Do you/your child tire easily? If so, describe when times are more difficult*

Do you regularly entertain friends and/or family at home?*

Does anyone visiting bring children or other dogs? If yes, please give ages and general attitude to dogs*

Do you and your family regularly go out in the evenings?*

Do you and your family regularly visit friends and/or family? If so, do they have children or other dogs? Please give ages and general attitude to dogs*

Info on any day centres/colleges/clubs that you/your child attends*

Days and times you/your child attends*

Able to take the dog if a parent is atte *

A suitable resting area for the dog?*

Training Information

When are you available?*

What is the minimum amount of notice required?*

Would you need an assistant to accompany?*

Assistant’s name and telephone number:*

Any additional information/comments:*

Autism Support Dog Application

Child Details

Primary Person Contact Details

Address Information

Parent/Guardian information

Other Information

Medical information

Information about the child

School Information

Mobility Information

Health Information

Other Enviroments

Costs Information

General Information

Routine Information

Training Information

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