Service Dog Application

Applicant Details

Application Type *

Salutation *

First Name *

Surname *

Identity Type *

ID Number *

Email Address*

Mobile Number*

Occupation*

Interest In Guide Dogs *

Gender*

Secondary Person Contact Details

First Name *

Surname *

ID Number *

Gender *

Phone Number *

Email Address*

Address Information

Residence *

Property *

Home Address *

Postal Address *

City *

Province *

Employment/School Circumstances

Employer *

Work Address *

Work Phone Number *

Name of School *

School Address *

School Phone No *

Lenght of Service *

What days/hours per week do you work? *

Will you be taking the dog to work? *

Has permission for a service dog been obtained? *

Is there a toileting area for the dog? *

Will you taking the dog to school? *

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

Own Animals Information

Dogs/Cats/Rabbits/Birds/Fish/Chickens etc. *

Are your dogs sterilised,Vacinated,Socialized? If not, why? *

Mobility Information

Describe your present indoor mobility: *

Describe your present outdoor mobility *

What type of mobility aid(s) do you use? *

How experienced are you with this equipment*

What speed do you walk? (If applicable) *

What speed do you travel in your wheelchair *

mobility aid(s)Other (Please specify) *

What degree of activity can you sustain? *

Disability Information

Type of disability *

Cause of Disability *

Date of onset *

Is condition stable or progressive? *

Pick up items off the floor? *

Push manual chair unaided? *

Put hands above your head? *

Self transfer? *

Do you require any specialist care on a regular basis? *

Health Information

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 *

Do you have epilepsy?*

Are you on any medication? If YES, please describe *

Do you attend regular doctor/hospital appoinments? If YES, please describe *

Can you maintain 3 or 4 hours activity pay day? *

Other Environments

Where will you take the dog? *

Places with children/other animals *

Place of Worship *

For what periods will the dog be left alone *

What hobbies or activities do you have *

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

Is your environments *

Please describe *

Do you go out alone? *

Do you drive? *

Type of transport *

Type of personal transport*

Can applicant

Pick up items off the floor (right hand) *

Pick up items off the floor (left hand) *

Turn lights on/off (right hand) *

Turn lights on/off (left hand) *

Bend/pick up objects *

Lift arm (right) *

Lift arm (left) *

Ability to use voice *

Ability to walk *

Please describe how you feel a Service Dog may enhance your life *

Training Information

What is the minimum amount of notice required *

Would you need an assistant to accompany *

Costs Information

During training, the cost of the dog, board and lodging and all equipment is R205 (Two Hundred and Five Rand). Can you afford this? *

It costs approximately R1500 (Five Hundred Rand) per month to provide for the dog. You will be required to take a pet insurance. Can you afford it?*

Plus R100 (One Hundred Rand) for your assistant’s board and lodging?*

You will be required to provide a bed and two stainless steel bowls for the dog. Can you afford this?*

What prompted your application?*

How did you hear about Service Dog?*

Additional Personal Details

Please tell us a little about yourself*