Canine Angels Service Teams

13475 N. Applegate Rd.
Grants Pass, OR. 97527
888 K9 ANGLS  or 541 846-6400
www.Canine-Angels.org email: info@Canine-Angels.org

Questionnaire

GENERAL INFORMATION
Last Name:
Mother's Name:
Father's Name:
Child's Name:
Childs's Age:
Childs's Gender:
Male Female
Address 1:
Address 2:
City:
State:
Zip:
Phone:
E-Mail:

Disability(ies):
Is disability progressive? Yes No
Does applicant use any of the following:
Is your child’s mental development at an average level? Yes No
Comprehension and ability to follow directions ok? Yes No
Working at what age level:
How is speech?
Do parents live together? Yes No
Mother's Occupation:
Please specify:
Father's Occupation:
Please specify:
Activity Level (Away from home):
What is a typical day like for the applicant and family?
Please list names and relationship of all people living in your home and ages of minors:
Has the applicant been exposed to dogs? Yes No
Was the interaction positive? Yes No
Any fear of certain kinds of dogs? Yes No
If yes, please explain:
Has the applicant family ever had a dog before? Yes No
Is anyone in the household allergic to dogs? Yes No

Please tell us about any pets in the household (breed, age, gender):
Whose idea was it to get an assistance dog?

How do you think your child will benefit from having an assistance dog?

What specific tasks would applicant/family like their dog to perform?
Do all family members agree on the decision to apply for an assistance dog? Yes No
If no, please explain:

Has the family considered the extra costs of having a dog, including quality food, dog supplies, and preventative care such as shots, heartworm and flea medication, and teeth cleaning?

 Yes No

Has the family considered the extra time for training, grooming, and exercise. Plus poop patrol. The dog must be picked up after 100% of the time…no exceptions.

Yes No

Is the family aware of the $25 application processing fee and $1,000 Team Training class fee (dog is provided free of charge)?

Yes No

Is the family aware that Team Training is located in Grants Pass, Oregon, and that travel, lodging, field trips, and some meals are the responsibility of the applicant family?

 Yes No
Is there anything else you would like Canine Angels to know?

How did you find out about Canine Angels Service Teams?