Freedom Service Dogs | Apply for a Dog

Please review the application instructions before completing this form. Your application will be reviewed and an interview scheduled when all information has been received.
Part A - Client Application, completed by client, a Video of your home and environment (still photos are fine if providing a video is difficult), two letters of recommendation and a $25.00 application fee.
Part B - Medical Form, completed by your physician or therapist, describing your disability. You will receive a link to download this form after successfully submitting Part A.

Date*

APPLICATION PART A

First Name *

MI

Last Name *

Date of Birth *

Age *

Height*

Weight*

Sex *

M
F

Address*

Street AddressCityStateZip Code

Home Phone *

Work Phone *

Employer

Cell Phone

E-mail

Name of Nearest Relative *

Relationship *

Address of Relative *

Street AddressCityStateZip Code

Relative's Home Phone Number *

Work Phone

This application must be IN THE WORDS OF THE PERSON WHO WILL USE THE DOG. If writing is difficult for you, provide name and relationship of person transcribing your words.

Name

Relationship

How did you learn about FSD?

Military Personnel Only:

Do you have a military affiliation?

What branch?

Are you Active or Retired?

Active
Retired

Please select from the following list the type of dog that would be best for your current situation:*

SERVICE DOG. A service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access. A service dog can be placed with a client that is at least 16 years of age or older and is capable of handling the dog in public without assistance.
SERVICE DOG - 3rd Party. A 3rd party service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access providing that a parent or guardian is with the client at all times when in public. Third party service dogs are available to clients that are under the age of 16 or unable to handle a dog in public without assistance from a guardian or care giver.
SKILLED COMPANION DOG. A skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. The dog is not granted public access and is trained to assist the client only in the home.
SKILLED COMPANION DOG - 3rd Party. A 3rd party skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. The dog is not granted public access and is trained to assist the client only in the home. A third party skilled companion dog is available to clients that are under the age of 16 or unable to handle a dog in the home without assistance from a guardian or care giver.

What is your disability? *

Most FSD dogs assist people with primary mobility impairment, such as multiple sclerosis, muscular dystrophy, cerebral palsy, spina bifida, paraplegia, tetraplegia, arthritis, amputation, stroke, or traumatic brain or spinal cord injury. FSD may also provide companion dogs for autistic clients. FSD does not train dogs to assist individuals with seizure disorders, blood sugar disorders or those with significant vision or hearing impairment.

How long have you been disabled? *

If disability was caused by injury, what progress has been made post injury?

Please indicate the devices that you use:

Please specify*

Which do you use most often? *

Do you *

Drive?
Take a bus?
Take a cab?
Other

Please specify*

Describe your physical strengths and abilities (Select one number for each limb).

LEFT 1 - No use, 10 - Full use

Hand Strength *

Dexterity *

Arm Strength *

Upper-Body Strength *

Leg Strength *

Leg Control *

RIGHT 1 - No use, 10 - Full use

Hand Strength *

Dexterity *

Arm Strength *

Upper-Body Strength *

Leg Strength *

Leg Control *

How often do you fall?

Can you catch yourself when you fall, or do you fall like a tree?

PLEASE RATE (On a scale of 1=Poor – to – 10=Normal):

Your Speech? Easily understood *

Your Speech? Tone variation *

Your Speech? Volume *

Do you use a word board? *

Yes
No

Your Vision? *

Do you use corrective lens? *

Yes
No

Do you need? *

Large font
Audio tape
Note taker
Other

Please specify*

Your Learning Ability? *

Need assistance, namely

Your Hearing? *

Hearing Aid
ASL

How do you handle the following?

Routine medications *

By yourself
Assisted
Provided by others

Your finances, checkbook *

By yourself
Assisted
Provided by others

Housecleaning*

By yourself
Assisted
Provided by others

Meals *

By yourself
Assisted
Provided by others

Getting dressed*

By yourself
Assisted
Provided by others

Shopping, groceries, etc.*

By yourself
Assisted
Provided by others

Personal Care*

By yourself
Assisted
Provided by others

What personal attendants (including family members) do you use?

Please specify*

Describe how many attendants and how often? (Daily, weekly?)

Please describe your limitations – mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, your ability to read and understand written material, and anything that might help us understand your needs.

What work, school, or rehabilitation program(s) have you completed?

What is your current work or school schedule?

What are your plans for work or school?

List the people living in your home, including their ages and their relationship to you.

Do any other members of your household have a physical or mental disability?

No
Yes

How are they disabled and what are their limitations? *

Please describe your home and yard. *

Is your yard fenced? *

No
Yes

How high is your fence? *

If your yard is not fenced, if your fence is too short or needs repair, will you be able to put up a secure fenced area before you receive your dog? *

Yes
No

What pets do you have now? Describe type and age.

Veterinarian’s name and phone number:

If you have a dog now, would you be willing to give up your present dog, if it cannot get along with an FSD dog?

Yes
No

Explain why.*

If your present dog is not well-mannered, are you willing to train your dog before you receive your FSD dog?

Yes
No

Explain why.*

What dogs have you had before? Describe what kind and how old you were.

On a daily basis, how will you handle walking, cleaning up after, feeding, medicating, exercising, grooming, and medical care for your FSD dog? *

How will you handle the care of your FSD dog if you are hospitalized? *

Will it be difficult for you?

• To attend placement classes at the FSD Training Center in Englewood, CO for four hours a day for 3 weeks? *

Yes
No

• To limit your calendar for the 30-day bonding period? *

Yes
No

• To attend an approved Obedience Class? *

Yes
No

Please explain any Yes answer.*

Living with a Freedom Service Dog

Do you agree to the following conditions?

• That there is a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years.*

Yes
No

Please explain.*

• That an FSD dog will spend most of their time with their partner at home AND at work, at school, and social events if he/she is certified for public access and that no FSD dog will be in a yard or kennel for long periods of time.*

Yes
No

Please explain.*

• That an FSD Dog is not a family pet – he or she has a specific function in their partner’s life and minimal interaction with others. *

Yes
No

Please explain.*

• That you and your dog are ambassadors for Freedom Service Dogs, as well as for the entire assistance dog industry (guide, hearing, and service dogs) and you will be expected to maintain your dog’s appearance and manners, as well as your handling skills.*

Yes
No

Please explain.*

• That an FSD dog cannot be allowed off leash except in a secure area. Exercise and elimination must be done on leash or in a fenced yard or dog run. *

Yes
No

Please explain.*

• That you must assume full responsibility as caretaker of your FSD dog, in charge of their safety, health, and welfare. Their needs INCLUDE:

1. Medical care – all care prescribed by your veterinarian and routine annual care as directed by FSD. *

Yes
No

Please explain.*

2. Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight. *

Yes
No

Please explain.*

3. Daily exercise and play.*

Yes
No

Please explain.*

• That you assume full responsibility for maintaining appropriate training and behavior, annually updating your ADI public access certification or Canine Good Citizen certification as applicable. You must maintain identification for public access, if applicable. *

Yes
No

Please explain.*

• That you must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage caused by your dog. *

Yes
No

Please explain.*

Sign below if you agree to the conditions listed above. Attach additional sheets if needed to explain any ‘No’ answer.

Your Electronic signature*

FirstLast

Date*

Video Outline

Please provide a 10-15 minute video in DVD format and submit with Part A of your application. Include the following information and label the video with your full name. If video equipment is unavailable to you still photos are fine, be sure to address ALL of the items listed below.
Your video is critical. FSD reviews it frequently during the placement process:

Initially, to see IF we can train a dog for your needs and accept you as a client
When matching teams, to evaluate whether a dog in training fits your lifestyle and your needs
During custom-training of the dog to meet your needs

1. Describe yourself

Name and address.
Tell us about your family, friends, and personal attendants.
Tell us about your pets (past and present).
Describe your daily routine – work, school, and other activities.

2. Describe your disability – Tell us about:

The history of your disability.
Your accomplishments.
Your limitations.
Your activity level.
Your daily routine.

3. Demonstrate your mobility level

Show us how you move around inside your home and workplace or school.
Show us how you use your adaptive equipment.
Show us how you transfer.
Show us your mode of transportation outside your home.

4. Describe what your dog would do

How do you think a dog will be able to help you?
What skills would you need?
What are your expectations of an assistance dog?
Do you currently have or have you ever had a service dog? If so:

a. Where did you get your service dog (organization, private trainer, self-trained, other)?
b. How many years did the dog work with you?
c. If you still have the dog, show your service dog interacting with you.

5. Show your environment

Home – Video the interior and exterior of your home, your yard (including any fencing), and your neighborhood (where you might walk with your dog)
Show your interaction with any present pets you may have.
Other – Video your work, school, recreational and/or social environment.

Please send video outline to:
Freedom Service Dogs, Inc.
2000 W Union Ave.
Englewood CO 80110
Fax 303-922-6234 info@freedomservicedogs.org

Letters of Recommendation

Please list the name and contact information of two people who will provide letters of recommendation for you.

1) Personal (not a relative).*

2) Professional (therapist, doctor).*

Please send letters of recommendation to:
Freedom Service Dogs, Inc.
2000 W Union Ave.
Englewood CO 80110
Fax 303-922-6234 info@freedomservicedogs.org