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**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
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What type of Service Dog are you Applying for?
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Mobility Service Dog (adults only)Psychiatric or Mobility Service Dog (for Veterans)Facility Service Dog
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Full name:
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Address:
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City
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Zip code:
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Phone number:
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E-mail address:
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Date of birth:
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(MM/DD/YYYY)
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Occupation:
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Place of business:
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Days and Hours employed weekly:
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Work telephone:
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If you volunteer, list your weekly commitment:
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Do you live within 45 minutes?
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YesNo
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Have you discussed this application with your family, employer and the place where you volunteer?
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YesNo
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If student, please list school name, address and current grade:
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School address:
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Current grade:
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If student, have you discussed this application with your school's principal?
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YesNo
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Schooling completed:
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Name of friend or relative we can call if we could not reach you: (if applicant is minor, list parent or guardian)
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Name:
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Phone:
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Relationship:
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Brief history of your disability:
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Age:
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Current weight?
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Curent height?
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Are you left or right handed?
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Are you a veteran?
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YesNo
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Is your disability service related?
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YesNo
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If you have had a spinal cord injury, please list the date of the accident and your spinal classification (C7 etc.)
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Please describe your upper body strength, especially the arms (range of motion) and hands (grip and dexterity.)
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Is one side (left or right) stronger?
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Do you bruise easily? Could a dog put his front legs up on your lap without hurting you?
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Do you have spasms in your arms or legs?
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YesNo
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Is it difficult for you to function in hot weather-or cold weather?
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Have you discussed this application with your doctor?
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YesNo
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Name of your physician:
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City of physician:
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State of physician:
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Address of physician:
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Phone of physician:
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Living arrangements
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Do you live in the City, Suburb, or Rural area?
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Please describe your neighborhood (busy road, neighbors close by, dogs/cats running free-examples)
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How many people live with you?
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Do you employ a personal care attendant?
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YesNo
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Do you use more than one PCA?
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YesNo
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If so, what hours do they assist you?
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Do you live in a house or apartment? 1 level or 2 levels
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Do you own or rent?
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RentOwn
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If you live in an apartment, what floor do you live on?
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How many units are in your building?
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If renting, have you discussed this application with your landlord
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Do you have a fenced yard?
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YesNo
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Could you put up a trolley run in your yard?
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YesNo
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Do you have many visitors?
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YesNo
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What are your hobbies or interests?
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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.)
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What types of transportation do you use?
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CarBusVanTrainPlane
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If you use both a manual and power wheelchair, please explain the situations in which each one is used.
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Do you transfer by yourself?
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CarNoN/A
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Please list any other information that may be of help to us in selecting the proper dog for you:
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Your training with the dog
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I can arrange to take off two weeks work/school to come to train with my new dog.
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YesNo
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Is fatigue a factor in your daily life?
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YesNo
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Do you smoke?
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YesNo
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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.)
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Where will your dog go toileting?
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When do you get out of bed in the morning?
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What time do you retire for the evening?
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Who will help with the dog's care if you are sick or cannot get outside?
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Helpers name:
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Helpers phone:
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Where will the dog be exercised and have playtime?
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Is there a particular type/breed dog that you do not like? (Golden or Labrador, male or female)
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Have you ever had a dog before?
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YesNo
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Do you or anyone in your household have a dog now?
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YesNo
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If so, what is the age of the dog? male/female neutered?
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Do you have any pets?
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Are your pets up to date on all vaccines?
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What Veterinarian do you use?
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Name of Veterinarian Clinic?
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Would you take your dog to work, school (if appropriate), social events?
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YesNo
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If not, where would the dog be?
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Do you travel a lot?
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Would you take the dog with you on trips?
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YesNo
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How many hours per day would the dog be alone?
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The size of dog I'd prefer:
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The reason I want a service dog is:
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Dog Training
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All dogs are taught basic dog obedience and socialized in public situations. What tasks do you want your dog to accomplish for you?
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What side do you need your dog to walk on?
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Aid in undressing?
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YesNo
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Carry articles in a dog backpack for you?
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YesNo
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Pick up dropped articles for you?
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YesNo
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Retrieve objects off counters or tables?
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YesNo
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Turn light switches on and off?
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YesNo
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Stand and brace for balance?
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YesNo
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Other tasks do you wish us to consider:
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Please enter the code shown in the image
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**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!
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