2322 44th ST NW Canton, Ohio 44709 330-493-7643 chipprogram1997@gmail.com

Application for a C.H.I.P. Service Dog

**We only serve people within a 45 minute drive from Canton, Ohio

To apply for disabled individual trained service dogs, please click here and download application

What type of Service Dog are you Applying for? Mobility Service DogPsychiatric Service DogVeterans Service DogFacility Service Dog
Full name:
Address:
City
Zip code:
Phone number:
E-mail address:
Date of birth: (MM/DD/YYYY)
Occupation:
Place of business:
Days and Hours employed weekly:
Work telephone:
If you volunteer, list your weekly commitment:
Do you live within 45 minutes? Yes
Have you discussed this application with your family, employer and the place where you volunteer? YesNo
If student, please list school name, address and current grade:
School address:
Current grade:
If student, have you discussed this application with your school's principal? YesNo
Schooling completed:
Name of friend or relative we can call if we could not reach you: (if applicant is minor, list parent or guardian)
Name:
Phone:
Relationship:
Brief history of your disability:
Age:
Current weight?
Curent height?
Are you left or right handed?
Are you a veteran? YesNo
Is your disability service related? YesNo
If you have had a spinal cord injury, please list the date of the accident and your spinal classification (C7 etc.)
Please describe your upper body strength, especially the arms (range of motion) and hands (grip and dexterity.)
Is one side (left or right) stronger?
Do you bruise easily? Could a dog put his front legs up on your lap without hurting you?
Do you have spasms in your arms or legs? YesNo
Is it difficult for you to function in hot weather-or cold weather?
Have you discussed this application with your doctor? YesNo
Name of your physician:
City of physician:
State of physician:
Address of physician:
Phone of physician:

Living arrangements

Do you live in the City, Suburb, or Rural area?
Please describe your neighborhood (busy road, neighbors close by, dogs/cats running free-examples)
How many people live with you?
Name Relationship Age
Do you employ a personal care attendant? YesNo
Do you use more than one PCA? YesNo
If so, what hours do they assist you?
Do you live in a house or apartment? 1 level or 2 levels
Do you own or rent? RentOwn
If you live in an apartment, what floor do you live on?
How many units are in your building?
If renting, have you discussed this application with your landlord
Do you have a fenced yard? YesNo
Could you put up a trolley run in your yard? YesNo
Do you have many visitors? YesNo
What are your hobbies or interests?
Do you have any other physical limitations such as sight or hearing loss that we should aware of? (Please note that C.H.I.P. service dogs do not perform any other type of assistance except mobility and/or psychiatric support.)
What types of transportation do you use? CarBusVanTrainPlane
If you use both a manual and power wheelchair, please explain the situations in which each one is used.
Do you transfer by yourself? CarNoN/A
Please list any other information that may be of help to us in selecting the proper dog for you:

Your training with the dog

I can arrange to take off two weeks work/school to come to train with my new dog. YesNo
Is fatigue a factor in your daily life? YesNo
Do you smoke? YesNo

Dog information

A successful service dog applicant must be able to care for the daily needs of his or her dog. Therefore we ask you to consider and answer the following: (Please indicate if you are unable to do a certain task.)

Where will your dog go toileting?
When do you get out of bed in the morning?
What time do you retire for the evening?
Who will help with the dog's care if you are sick or cannot get outside?
Helpers name:
Helpers phone:
Where will the dog be exercised and have playtime?
Is there a particular type/breed dog that you do not like? (Golden or Labrador, male or female)
Have you ever had a dog before? YesNo
Do you or anyone in your household have a dog now? YesNo
If so, what is the age of the dog? male/female neutered?
Age:
Sex:
Neutered:
Do you have any pets?
Are your pets up to date on all vaccines?
What Veterinarian do you use?
Name of Veterinarian Clinic?
Address: City:
State: Zip Code:
Veterinarian's Phone number:    
Would you take your dog to work, school (if appropriate), social events? YesNo
If not, where would the dog be?
Do you travel a lot?
Would you take the dog with you on trips? YesNo
How many hours per day would the dog be alone?
The size of dog I'd prefer:
The reason I want a service dog is:

Dog Training

All dogs are taught basic dog obedience and socialized in public situations. What tasks do you want your dog to accomplish for you?
What side do you need your dog to walk on?
Aid in undressing? YesNo
Carry articles in a dog backpack for you? YesNo
Pick up dropped articles for you? YesNo
Retrieve objects off counters or tables? YesNo
Turn light switches on and off? YesNo
Stand and brace for balance? YesNo
Other tasks do you wish us to consider:
Please enter the code shown in the image
 

**Please review the information you have provided. You will not be given an opportunity to edit this information, after you click the submit button. Thank you!