Please fill out all of the form to the best of your abilities. Read the terms carefully. Minors under 18 years of age will need a consenting guardian to also sign for them.
Your Full Name:
Diagnosed known conditions:
What aids do you use, if any?
Do you live with others? YesNo
If yes, how many:
Do they all agree on a dog in the home? YesNo
Do you have any other pets in the home? YesNo
Will they be ok with a dog? YesNo
Please choose an occupation: StudentWork full timeWork part timeOther
Have you discussed having a service dog with your supervisor? YesNo
Are you applying with a pre owned dog that you would like certified? (please note this requires further assessment) YesNo
Leash of Hope requires three letters of reference that MUST accompany this application. This includes a letter from a medical professional, and two letters from either a teacher, landlord, parent, employer or other member of the community in good standings.
Leash of Hope requires a letter in full from the applicant stating their reasons for applying for a dog through our program and what makes them a good candidate. If a written letter is a difficult form of communication, an applicant can also submit a video or audio recorded presentation.
Please read carefully. Signing below indicates that you have read and agree to all terms.
A $25 administrative fee must be sent with this application in order for you to be placed on our active waiting list for an assistance dog. should be made payable to Leash of Hope. Please contact us if you would like to make this payment by cheque or money orders or email money transfer.
The full program fee is $3000.00, this can be paid in full or on a payment plan. *A subsidized rate is available for those who are low income.* Please indicate how you wish to complete this payment: ChequeCredit CardEmail Money TransferMoney OrderPayment Plan (We will contact to arrange)
Clients that do not follow their payment plan and do not make new arrangements for payment will receive official warnings and may result in removal of the dog.
Note: If the application is received incomplete or without application fee your application will be placed in our inactive file until the fee and all incomplete sections are received. Review of this application will take 3 to 5 business days when we will contact you. Thank you.
Application's Signature (type name):
Guardians Signature (If under 18) (type name):
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Office: 4501 Kingsway, Burnaby, BC
Phone: +1 (778) 879-3858
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