Leash of Hope Assistance Dog Application Form

Part 1: Personal Information:

Your Full Name:

Birth Date:

Phone:

eMail:

Address:

Diagnosed known conditions:

What aids do you use, if any?

Do you live with others?  Yes No

If yes, how many:

Do they all agree on a dog in the home?  Yes No

Do you have any other pets in the home?  Yes No

If yes, how many:

Will they be ok with a dog?  Yes No

Please choose an occupation:  Student Work full time Work part time Other

Have you discussed having a service dog with your supervisor?  Yes No

Are you applying with a pre owned dog that you would like certified? (please note this requires further assessment)  Yes No

If Under 18 - Guardian's information:

Full Name:

Relationship:

Phone:

eMail:

Part 2: References

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.

Part 3: Application Letter

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.

Part 4: Policies

Please read carefully. Signing below indicates that you have read and agree to all terms.

• I agree to a secondary interview and home check.
• I agree to assume financial responsibility for my assistance dog, including basic and extensive care and whatever other necessities the dog may require in order for it to perform to its fullest capacity as an assistance dog.
• I agree to participate in all the team training program that has been customized for me and to communicate with my trainer in full if rescheduling is required.
• I agree that the assistance dog placed with me will not be placed in the care of anyone at any point in unless approved by Leash of Hope.
• I agree that if I fail to meet the requirements and the policies above then three official warnings can be issued which may result in the removal of the dog.
• I am prepared and committed to working with/receiving a dog over the next six months. If my availability changes I will inform Leash of Hope and understand that this may affect my placement on the waiting list.
• I agree to keep channels of communication open between Leash of Hope or designate an advocate in the event that I cannot do so. This includes providing 24 hrs notices for rescheduling of any team training.

For Guardians:

• I agree to participate to the full extent that is required of me while the applicant in question participates in the program.
• I agree to assume financial responsibility for the assistance dog, including basic and extensive care and whatever other necessities are required for the dog to function at its fullest capacity as an assistance dog.
• I agree to keep open communication channels between the applicant and Leash of Hope in the event that the applicant is unable or fails to do so.

Part 5: Fees

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 $600.00, this can be paid in full or on a payment plan. Please indicate how you wish to complete this payment:  Cheque Credit Card Email Money Transfer Money Order Payment 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):

Date:

Date: