Initial Student Application

Contact Information:

First and Last Name

Street Address

Town

State Massachusetts Maine Vermont New Hampshire Connecticut Rhode Island

Zip Code

Home Phone

Cell Phone

E-mail Address:

DOB:

Age:

Height:

Living Situation:

Number of Adults Living in the Home:

Number of Children Living in the Home:

Ages:

Do you live in a: House Apartment Group Home Other

Of "Other" please describe:

Do you have a fully fenced back yard? Yes No

If yes, what size approximately?

Disability Related Information:

Diagnosis

Date of Onset

Is your condition progressive? Yes No

How do you expect it to change over the next 3-5 years?

Please describe how your disabling condition affects your day to day functioning:

Please describe how you believe a dog could assist you in your daily functioning:

Please list any other conditions that you feel may impact your ability to properly train with, maintain or care for a Service Dog:

Please note that we also require medical documentation of your disability from a Medical Doctor, Licensed Social Worker or Psychologist, as well as an overall health form from your Primary Care Physician.

Activity Level & Personality:

While every dog is different, a working Service Dog does require a certain amount of both physical and mental stimulation on a daily basis.  Therefore it is important for us to know what your normal daily routine is like.  In the following box, please describe to us a usual week day and usual weekend day for you:

Outside of your normal routine, how do you plan to exercise your Service Dog?

In an attempt to match each dog with the most appropriate candidate, we would like to hear how you describe your personality and how that may relate to a dog.

Animal History:

Have you ever had a pet before? Yes No

If Yes:

What kind/breed?

How many?

What happened to said pets?

Do you currently have any pets? Yes No

If Yes please describe: breed/species, age, sex

Have you ever had a Service Dog? Yes No

If Yes:

Where was he/she trained?

May we contact your previous school or trainer for more information? Yes No

Please list contact information

Where is said dog currently?

What are your plans for said dog when you obtain a new Service Dog?

Please describe your ideal dog: temperament, coat length, breed, size, sex, temperament. 

Are you financially able to properly care for and feed a dog (approximately $60-80 per month)? Yes No

Name of most recent veterinarian: 

Phone number of most recent veterinarian: 

Address of most recent veterinarian:

Is there anything else you would like us to take into consideration in potentially placing a Service Dog with you?

Program Type:

Which MAP Program are you most interested in acceptance into? Facility Trained Owner Trained Emotional Support Dog

Why?

Other:

I understand that completing this application does not place me nor Maplewood Assistance Partners, Inc. under any obligation.  It assists Maplewood Assistance Partners, Inc. in assessing my need and eligibility for training with a service dog. 

Maplewood Assistance Partners, Inc. prohibits discrimination based on race, color, creed, gender, religion, marital status, age, national origin or ancestry, physical or mental disability, medical condition including genetic characteristics, pregnancy, sexual orientation, citizenship status, military service status, or any other consideration made unlawful by federal, state or local laws.

Signed:

Date:

Information Release:

Before submitting this On-line Application, please fill out and print, then mail in the Information Release. We cannot proceed with your application process until we have received the printed and signed Information Release.