Noelle's Dogs Four Hope
Your Four Legged Miracle Begins Here ...
Web Page
Application
For a Service Dog...

Dear Applicant,

The following application is intended for gathering information for assessment purposes.  This will help us understand more about you and your lifestyle and therefore, determine which type of dog and which of our dogs in particular might be the best fit. 
 
Please be thorough and complete all questions to the best of your knowledge.
 
Noelle's Dog's Four Hope does reserve the right to deny services to any applicant which does not meet criteria necessary for training or placement of a Service Dog or who requires services not trainable within the guidelines of the organization.
 
If accepted into the program, further documentation may be required but not limited to:
  • Emergency Information
  • Medical Information and release form
  • Three References of people not related to the PDR
  • Etc.   
We Moved to Our New Site: 

 

 

* Required fields
Name *
E-mail Address *
Date: *
Age of PDR/ DOB *
Address: *
City: *
State: *
Zip: *
Home Phone: *
Work Phone:
Cell Phone:
Occupation *
Would you be available to travel to Colorado for TWO weeks for client training? * Yes
No
Are you: *
What is the primary diagnosis? *
List other medical issues... *
What other methods have you tried to control the diagnosis? List medications, operations, etc. *
If PDR has seizures, what type are they and how often do they occur? *
How does this affect daily living? *
What are your limitations? *
How do you describe your lifestyle? *
List the physcial activities performed on a regular basis. *
What are the primary modes of transportation? *
Type of residence: *
List all people currently living at the same residence and their relationship. *
Are there other pets in the home? Species (cat, dog, other?) *
Do they live inside? Y/N If not, where do the other pets live? *
Do you have a fenced yard? *
If not, do you plan to fence the yard and what type? *
What type of service dog are you seeking? * Seizure Response
Allergy Alert
Psychiatric
Stability
Other
What do you think a service dog is? *
What tasks would you like a service dog to help you with to become more independent? *
Have you ever had an experince with a dog? If so, please describe. *
* Are you physically able to handle a dog? Y/N If not: Who will handle the dog for you? Please explain: *
How would you excercise the dog? They need a least 30 minutes a day. Can you provide that and how? *
Can you feed the dog? *
Can you afford Veterinarian costs? *
Can you groom the dog? *
If you cannot afford to feed, groom or provide vet costs, please explain. *
This is the place to tell Noelle's Dogs Four Hope anything you would like us to know more about you and your desires. *
A dog has it's own personality and needs and it is not simply a machine. * I understand
I do not understand
Please clarify
On going life time, daily training is needed for a service animal. Do you understand that you will need to continually train the service animal daily for it's entire working life? * YES
no
SEIZURE RESPONSE SERVICE DOG APPLICANTS: Do you clearly understand that a service dog cannot be trained to alert to a seizure? * YES
no
N/A

I have read and agree to the Privacy Policy *

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