certify that the information 

(print name) 

provided in this application is true and correct, AND understand and agree: 

10. to give permission to WLC to verify this information through whatever reasonable means necessary. 
11. that clients and dogs are matched based on a number of factors including compatibility and training requirements and not on a “first come, first served” basis. 
12. After receipt of this application package, Medical History and Professional Reference forms, WLC will contact me about scheduling a personal interview .
13. that WLC will schedule a home visit and, if applicable, visit my work environment. 
14. If there are existing pets in the home, a WLC dog will be brought to my home to interact with my pet(s) as part of the home visit. WLC staff will determine if the pet(s) will be compatible, behaviorally and medically, with a WLC dog. 
15. that I will maintain no more than one other dog in my household at the time of placement of a WLC dog unless approved by WLC. Further, I agree that if a WLC dog is the sole dog in my household, I will not acquire another pet dog within the first year of placement. 
16. that being accepted into the WLC program does not guarantee placement with a dog. WLC reserves the right during this process (up to and including Team Training) not to make a placement with any applicant who is, for any reason, not able to meet WLC standards to manage care for an assistance dog effectively and safely. 
17. that my acceptance into the WLC program will be decided without regard to race, religion, color, gender or sexual orientation. 
18. that all information contained in this application will remain confidential and property of WLC. 
19. that I authorize my veterinarian to release any information requested by WLC. 
20. that I have the financial responsibility of caring for the assistance dog, including providing quality food, veterinarian visits, all health care, and professional grooming (if I cannot do the latter myself). 
21. that all WLC dogs must be on leash at all times in all indoor and outdoor public venues, unless that venue is a park or other facility with a designated, secured off-leash area. The dog’s leash must be hand-held or otherwise attached to their handler or a wheelchair.

*If the applicant is a minor, under guardianship, conservatorship/or a ward of the court, the parent or guardian is required to sign below pursuant to state and federal law.

Authorization to Release Medical History 

Applicant Instructions: Please provide the information requested below. Give this page and the attached Medical History Form to your Physician. Once completed, the forms should be returned to WLC.

Physician,

Please release to WLC any requested information regarding my condition. The information you provide will be used to evaluate and assess my application for a WLC Service Dog. WLC will keep this information strictly confidential and will not share it with anyone but the professional staff of the agency that is involved in evaluating my application request or in providing services for me. 

Medical History Form 

To the Physician: Please complete this form and return it to the WLC. This form is needed to complete your patient’s application for a WLC Service Dog. The information provided will help WLC determine the applicant’s suitability for a service dog, and to plan a training program that takes into consideration the applicant’s medical conditions. All medical information about the applicant will be kept strictly confidential.