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APPLY FOR A DOG
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About Us
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Services
Get Involved
Jobs & Internships
Support
Contact
APPLY FOR A DOG
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Service Dog Application
service dog
Step
1
of
7
14%
Your residence
Incomplete or poorly completed applications will not be considered. Please answer each question carefully and fully.
First Name
(Required)
Last Name
(Required)
Email
(Required)
Date of birth
Street Address
(Required)
City
(Required)
State
Zip Code (5 digit)
(Required)
Place of residence
(Required)
rural
urban
suburban
Type of residence
(Required)
single family
apartment
Other
Do you own your home?
(Required)
Yes
No, tenant
Other
Is your living space adapted to your needs?
What interior and exterior modifications do you have? (Optional)
Access ramp
Elevator
Automatic door
Modified bathroom
Lowered counters
Grab bars
Other modifications (Optional)
Technical aids
Do you use a technical aid? (cane, crutches, basic walker, rollator?)
(Required)
Yes
No
Other
If yes, which of these technical aids do you use?
Cane
Indoors
Outdoors
n/a
Crutches
Indoors
Outdoors
n/a
Basic walker
Indoors
Outdoors
n/a
Rollator walker
Indoors
Outdoors
n/a
Manual wheelchair
Indoors
Outdoors
n/a
Electric wheelchair
Indoors
Outdoors
n/a
Three/Four-wheel scooter
Indoors
Outdoors
n/a
Your needs
Physical condition Medical diagnosis of your disability
Please describe your diagnosis using general and medical terminology
(Required)
When did you receive your diagnosis?
(Required)
Is your condition stable?
(Required)
Yes
No, it’s progressive
Do you have any associated conditions? If so, please describe.
(Required)
Do you have any allergies? If so, please describe (If applicable)
(Required)
Specify any other health problems (if applicable)
(Required)
Does anyone who will also live with the dog have allergies? If so, please specify (if applicable)
(Required)
Do you use rehabilitation services? What kind?
(Required)
Example: Therapy, physical therapy, in/outpatient treatment, etc. In other words, who diagnosed and/or supports you clinically with your disability? Please note that we do require that our clients have been in ongoing therapy for a minimum of one year, receive ongoing care, and provide us with documentation supporting the need for a service dog for PTSD.
If so, please provide the names and contact information of the people who help you (if applicable)
(Required)
Your motor skills
Can you pick up an object from the ground?
Yes, without difficulty
Yes, with a grabber
Yes, in another way
No
If you selected Yes, in another way or No, please explain (if applicable)
Can you push elevator buttons?
Yes, without difficulty
Yes, with a grabber
Yes, in another way
No
If you selected Yes, in another way or No, please explain (if applicable)
Can you open doors? (check boxes)
Yes, without difficulty
Yes, if there’s space to move around
Yes, if the door isn’t heavy
Yes, only with lever handles
Yes, other difficulty
No
If you selected Yes, in another way or No, please explain (if applicable)
Can you undress alone? (jacket, sweat, sock, shoes)
Yes, without difficulty
Yes, with difficulty
Yes, in another way
No
If you selected Yes, in another way or No, please explain (if applicable)
Can you move from your wheelchair to your bed?
Yes, without difficulty
Yes, with difficulty
Yes, in another way
No
N/A
If you selected Yes, in another way or No, please explain (if applicable)
Can you move your wheelchair?
Yes, without difficulty
Yes, only inside or on flat surfaces
Yes, only over short distances
Yes, painfully
Yes, in another way
No
N/A
If you selected Yes, in another way or No, please explain (if applicable)
Can you walk?
Yes, without difficulty
Yes, only inside or on flat surfaces
Yes, only over short distances
Yes, painfully
Yes, in another way
No
If you selected Yes, in another way or No, please explain (if applicable)
Can you use the stairs?
Yes, without difficulty
Yes, only a few steps
Yes, only with a handrail
Yes, in another way
No
If you selected Yes, in another way or No, please explain (if applicable)
Social Situation and Family environment
You live:
(Required)
Alone
With family
With roommates
With spouse/partner
Other
If other, please specify
Are there any kids that live with you?
(Required)
Yes
No
Please list all the people who live with you (if applicable) (Include their name, age, and relation to you)
(Required)
Do all of the people who live with you agree with your course of action?
(Required)
Yes
No
If some disagree with your decision, please list their concerns (if applicable)
Is there anyone in your family that does not like dogs?
(Required)
Yes
No
If yes, please explain.
Does anyone in this house have a fear of dogs?
(Required)
Yes
No
If yes, please explain.
Do you have any other pets at home?
(Required)
Yes
No
Please include all pets, not just dogs. Please list their age, breed, name, Sex, Spayed/Neutered? etc.
(Required)
Method of transportation commonly used by applicant/ family
(Required)
Personal vehicle
Public Transportation
Other
Does your home have a fenced-in yard?
(Required)
Yes
No
If not, please explain how you will contain the dog:
(Required)
Please describe your fence. What type of fence? How tall is it? Is it fully enclosed? Is your fence well-maintained and in good shape?
(Required)
A fenced-in yard is very good for exercising a young service dog; however, a dog also needs daily walks on leash. Is the dog’s primary handler physically able to handle the strength of a young, active 65-85 pound dog?
(Required)
Yes
No
If not, who will be exercising the dog?
Is the dog’s primary handler physically able to walk two miles on a daily basis?
(Required)
Yes
No
If the primary handler is not physically able to walk two miles on a daily basis, is there someone who is able to do so? Please list their name and contact information below.
(Required)
Are there any physical challenges with the primary handler of which FRSD should be aware? This is important for dog matching purposes. Examples: handler with back injury, upcoming surgery, orthopedic injuries or ailments, etc.
(Required)
Are there any physical challenges with the individual who is responsible for walks/exercise of which FRSD should be aware? This is important for dog matching purposes. Examples: parent(s) with back injury, upcoming surgery, orthopedic injuries or ailments, etc.
(Required)
Do you consider yourself knowledgeable in dog care and behavior?
(Required)
Yes
No
Who is part of your support system?
(Required)
Is the entire family and/or support system committed to the idea of having a service dog?
(Required)
Are you prepared to deal with the time involved in maintaining a service dog (socializing, on-going training, exercising, grooming, toileting, etc.)?
(Required)
Yes
No
Are you able to financially commit to maintaining a service dog, which can cost over $1000 / year for veterinary care and food expenses? This does not include unforeseen circumstances.
(Required)
Yes
No
Do you understand that FRSD's placement process entails: 1. A two week structured training program when matching a client and their dog. 2. After successful completion of that program the team is required to commit to a minimum of a year long weekly training program working on public access skills to help ensure the success of the team. This training and the initial two week structured team training will both take place in the Lakes Region of New Hampshire. 3. After the minimum of a year of training, there is a requirement of a biannual public access test and home visit to ensure that training standards and being maintained and the client receives follow up training.
(Required)
Yes
No
Due to the nature of service dog training there will likely never be enough service dogs available to match the demand for service dogs. Completion of this application does not guarantee the availability of a dog.
A Foliage Retrievers Service Dog attracts a great deal of attention out in public. Are you comfortable being in the public eye? How will you deal with the attention you and the dog receive?
(Required)
How long have you considered getting a service dog?
(Required)
Why do you feel you are ready now?
(Required)
How much time per day do you have to care for a dog?
(Required)
Who will care for the dog in the event that you are unable to?
(Required)
Social situation
What is your lifestyle?
(Required)
I stay at home most of the time
Active, I get out into the community often
Describe your lifestyle - list activities and outings applicant and family enjoy, including weekends, summer camps, traveling, etc.
(Required)
Please add as much detail as possible. This application is meant to help us get to know you.
Job
(Required)
Full-time
Part-time
Seasonal/temporary
Student
Unemployed
Where do you work?
Have you discussed the possibility of bringing a service dog to work with your employer?
Are you in school?
(Required)
Yes, in-person
Yes, virtually/online
No
If you are a student in school, what grade are you in?
Elementary school (1-6 grade)
Middle school (7-8th grade)
High school (9-12th grade)
College (2 year)
College (4 year)
Graduate program
Not a student
Other
If other, please specify
Have you discussed the possibility of bringing a service dog to school with the director of your school?
(Required)
Yes
No
N/A
Your expectations
Please describe how you believe a service dog will be beneficial and improve your autonomy in your daily life?
(Required)
Please describe how your disability impacts your life?
(Required)
What are you currently having difficulty or unable to do that you would like to do?
(Required)
What tasks would help you accomplish what you’ve had difficulty or been unable to do due to your disability?
(Required)
Please note that under the ADA "the work or task a dog has been trained to provide must be directly related to the person’s disability. Dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA."
Which of the following type(s) of disability are you applying for a dog to assist with?
(Required)
PTSD
Physical
Psychiatric
Chronic illness
Other
Please note: we currently only train service dogs for individuals with PTSD.
If you selected Other, or you would like to elaborate please feel free to do so here.
Since Foliage Retrievers Service Dogs was founded with the mission of serving disabled individuals that are currently underserved by service dog organizations we want to learn more about you. We want to know if or why you feel you meet the criteria of being underserved by other service dog organizations. (Please note: we may currently be unable to assist with certain needs, however, we use this information to inform decisions about the future of our program and how we can bridge gaps)
(Required)
Did you read our program requirements listed on the services page under "Is FRSD the best fit?"
(Required)
Yes
No
If not, please go read those and make sure that you understand our program requirements and eligibility criteria. As a small organization we are unable to respond to every application and due to lack of availability of service dogs we are unable to meet demand.
Do you understand that FRSD only trains Labrador Retrievers and does not train “hypoallergenic” breeds.
(Required)
Yes
No
Do you understand that if accepted into the program clients are expected to raise a minimum of $9,000?
(Required)
Yes
No
The cost of raising a service dog is approximately $50,000. FRSD asks clients to show their commitment to the organization by essentially become a part of our fundraising team by raising a minimum of $9,000. This contribution goes towards the operating costs involved in raising, training, and matching our unique and highly skilled dogs. After being accepted into the FRSD program you will meet with an FRSD representative to develop a fundraising plan.
If you have not done so yet, please send documentation from your doctor(s)
Comments
This field is for validation purposes and should be left unchanged.
