Service Dog Application

000_00431

Jordan Family Service Dog Application
Harrisonville, MO
(816)293-5155
www.jordanfamilykennels.com

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Please print and fill out all information in the Service Dog Application Form and return it to us with a letter from your doctor stating that you are in need of a Service Dog. You can use extra paper to give detailed information. You can call for our address to send through usps, or you can scan and email all requested info to us. Our service dogs are donated ‘at cost’ to families that agree to have the puppy used for a medical disability and not just family pets. If you receive a service dog from us you agree to have it spayed/neutered once you receive it, and have him/her enrolled in puppy classes before you receive him/her. All service dogs need ongoing training and need to eventually get their Canine Good Citizenship Certificate. At cost on a Giant Schnauzer puppy would be $500. That is the cost what we have in the puppy in care and training. Shipping is also the responsibility of the adopter and usually runs $300 to $350 within the US. We can only donate 2 pups per a litter, so there may be a wait. Puppies are donated on a Triage Bases… So a wheelchair bond person needing a large service dog to retrieve dropped object and support mobility will be considered before someone who needs a emotional support dog. Please call with any questions. If dog is for a minor child under 18 years of age, or if applicant is unable to do so, the legal guardian or representative should fill out this form. I would also suggest if you truly want a bonded medical service dog that it be the only dog in your home. If another dog is around your Schnauzer may bond with it instead of the person it is meant to bond to.

Applicant Name _________________________________ DOB ___________________

Age __________________________ M/F _________________

Address ___________________________________________________________

City ____________________________ State _________ Zip _________________

Phone __________________________ Phone 2 ___________________________

Cell ________________________________ Cell 2 _________________________

Fax _______________________________________________________________

Email _____________________________________________________________

_____ Married _____ Single _____Other ____________

Spouse Name ______________________________________________________

Employer __________________________________________________________

Position/Title _______________________________________________________

Address __________________________________________________________

City ______________________________ State _______ Zip ________________

Phone _________________________________ Ext. _______________________

There how long? ______________ Contact Name __________________________

If Applicant is a minor, please have parent/guardian complete form:

Parent/Guardian Name _______________________________________________

Address __________________________________________________________

City __________________________________ State ________ Zip ___________

Phone __________________________ Phone 2 __________________________

Cell ____________________________ Other ____________________________

Email ______________________________ Other ________________________

_____ Married _____ Single _____Other ________________________________

Spouse Name _____________________________________________________

Employer _________________________________________________________

Position/Title ______________________________________________________

Address _________________________________________________________

City _________________________________ State _______ Zip ____________

Phone __________________________________ Ext. _____________________

There how long? ___________ Contact Name ____________________________

Please list all children in the household:

Name ________________________________M/F ___________ Age _________

Medical History of Applicant:_________________________________________________________

________________________________________________________________

Medical Diagnosis:_________________________________________________

________________________________________________________________

Years with disabilities: _________________________________________________________________

All Physical Challenges due to disability:__________________________________

________________________________________________________________

Do you have a caregiver or medical attendant?
If so, how often do they come and give medical attention and what do they do:

________________________________________________________________

Do you use a cane, walker or wheelchair? Please describe in detail: Yes/No

________________________________________________________________

Do you drive? If so what make of vehicle:
_________________________________________________________________

Are you an outdoor person or indoor person? Please describe all your activities and hobbies:
_________________________________________________________________

________________________________________________________________

Do you participate in rehabilitation or therapy? Please describe:

________________________________________________________________

Service Dog Requirements:

Type of service dog you want to achieve: Service Mobility Hearing Physic. Therapy:

_______________________________________________________________

Would your Service Dog accompany you everywhere? Yes/No

What qualities do you need in a Service Dog?
_______________________________________________________________

_______________________________________________________________

What tasks do you need in a Service Dog?
_______________________________________________________________

_______________________________________________________________

Could you provide the dog with veterinary care, heart worm preventive, flea control, grooming,
exercise and feeding?
_________________________________________________________________

If you are unable to do the daily tasks of feeding and care of the Service Dog, who would be the one to help you with the dog?
_________________________________________________________________

In the event of your death who would take over care of your service dog?___________

_________________________________________________________________

Do you have other dogs inside your home?_______ Name(s) _________________

M/F ____ Age(s) _______ Breed(s) ____________________________________

Please describe your expectations of the "perfect" Service Dog and how it could help your quality of life.
_________________________________________________________________

_________________________________________________________________

Anything else you would like for us to consider in reference to you obtaining a Service Dog?
_________________________________________________________________

_________________________________________________________________

Applicant Signature: ______________________________________________

Printed Name: __________________________________________________

Date: ________________________________

For Office Use Only:

Received:___________________________________
Approved:___________________________________
Meeting Date: ______ Where: ___________________
Home Visit / Phone visit Date: _____________________________
Follow up: __________________________________

Notes: __________________________________________________________

Service dog breeder: Kristina Jordan: 816-293-515

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