Service Dog Application Form Please enable JavaScript in your browser to complete this form.LayoutWolfhounds Legacy Service Dog Application FormLocations:Florida location239-601-6786wolfhoundslegacy@gmail.com 229 NW 22nd Pl Cape Coral, Florida Wisconsin Location 414-813-6927 wolfhoundslegacyWI@gmail.com S72W13684 Woods Rd Muskego, WI Service Dog Application Form Instructions: Please complete and return the following items to Wolfhounds Legacy • Service Dog Application Form • Signed Applicant Agreement • Vaccination records for current pets (if applicable) • Medical History Form: Have your physician complete and mail the form to WLC • Professional Reference Form: Have your PT, OT, Caseworker, Psychologist or Rehab Counselor complete and mail the form to WLC Service Dog Application Form Today’s Date: Applicant Information Name:State applying for service dogWisconsin LocationFlorida LocationAddress:LayoutCell Phone:Home:Work:Email *Household Information1) Do you live in a:HouseCondoApartmentDuplexMobile Home2) Do you:RentOwnLive with relatives3) Fenced Yard:YesNoPlease list all members of your household: Name & RelationAutobiographyPlease use this page (and additional pages, if needed) to tell us about yourself. Include a description of your typical daily activities and places you go on a regular basis. Also describe how your disability affects your life and your current level of independence.APPLICANT AGREEMENT, (print Name) certify that the information provided in this application is true and correct, AND understand and agree: 1. To give permission to WLC to verify this information through whatever reasonable means necessary. 2. 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. 3. After receipt of this application package, Medical History and Professional Reference forms, WLC will contact me about scheduling a personal interview. 4. That WLC will schedule a home visit and, if applicable, visit my work environment. 5. 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. 6. 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. 7. 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. 8. That my acceptance into the WLC program will be decided without regard to race, religion, color, gender or sexual orientation. 9. That all information contained in this application will remain confidential and property of WLC. 10. That I authorize my veterinarian to release any information requested by WLC. 11. 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). 12. That all WLC dogs must be on a 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 handheld 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. LayoutApplicant/Guardian NameDateLayout (copy)Applicant/Guardian Signature Clear SignatureAuthorization 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.Applicant NameAddress:PhonePhysician, 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. LayoutApplicant/Guardian Signature Clear SignatureMedical History FormTo 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. Physician Information Name:Address:PhoneApplicant Information1) Applicant’s Name: 2) What is the applicant’s primary disability? 3) What is the prognosis of the disability? Please list any secondary disabilities:4) Does the applicant’s disability affect their cognitive abilities or functioning in any capacity? Yes / No If (yes, please describe5) Does the applicant have a history of seizures? Yes / No YesNo6) Do you have any concerns about the applicant’s ability to physically tolerate the training required to work with a service dog? Yes / No (If yes, please describe)7) Do you have any concerns about the applicant’s ability to cognitively participate in the training? Yes / No (If yes, please describe)8) Do you have any concerns about the applicant’s ability to care for a service dog? Yes / No If yes, please describe: 9) Why do you feel the applicant would benefit from having a service dog? 10) Are there any additional comments you wish to make that might help us in evaluating your patient’s application for a service dog? LayoutYour SignatureClear SignatureDate ** Thank you **Professional Reference Form PART A*Applicant Instructions: Please provide the information requested on the first page of this form (PART A). The Professional Reference Form (Part B) should then be completed by your Occupational Therapist, Physical Therapist, Rehabilitation Counselor, Psychologist or Case Worker. The completed form should be returned to WLC.PART AApplicant NameAddress:PhoneHealthcare Provider, Please release to the 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.Applicant Signature & Date Clear Signature* If the applicant is a minor, or under guardianship or conservatorship or a ward of the court, the parent or duly authorized representative is required to sign below pursuant to state and federal law. Guardian Name (print) & Date Guardian SignatureClear SignatureProfessional Reference FormPART BTo the Healthcare Provider: Please complete this form and return it to the WLC Service Dogs. 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. Provider Information NameTitle:Address:PhoneApplicant Information1) Applicant’s Name:2) What is the applicant’s primary disability? 3) What is the prognosis of the disability? 4) Please list any secondary disabilities: 5) Does the applicant’s disability affect their cognitive abilities or functioning in any capacity? Yes / No (If yes, please describe)6) Do you have any concerns about the applicant’s ability to physically tolerate the training required to work with a service dog? Yes / No (If yes, please describe)7) Do you have any concerns about the applicant’s ability to cognitively participate in the training? Yes / No (If yes, please describe)8) Do you have any concerns about the applicant’s ability to care for a service dog? Yes /No (If yes, please describe)9) Why do you feel the applicant would benefit from having a service dog? 10) Are there any additional comments you wish to make that might help us in evaluating your patient’s application for a service dog?LayoutYour Signature Clear SignatureDateSubmit Applicant InformationName *Address *Phone *Home PhoneWorkCellEmail Address *HomeWorkHousehold InformationDo you live in a: *HouseCondo Apartment DuplexMobile Home (circle one) Do you:RentOwnLive with relatives (circle one) Type of animalAddiotnals pets in the homeYesNoFenced Yard:Yes NoPlease list all members of your household:NameRelationshipAgeAPPLICANT AGREEMENTI *certify that the information (print name) provided in this application is true and correct, AND understand and agree: to give permission to WLC to verify this information through whatever reasonable means necessary. 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. After receipt of this application package, Medical History and Professional Reference forms, WLC will contact me about scheduling a personal interview . that WLC will schedule a home visit and, if applicable, visit my work environment. 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. 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. 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. that my acceptance into the WLC program will be decided without regard to race, religion, color, gender or sexual orientation. that all information contained in this application will remain confidential and property of WLC. that I authorize my veterinarian to release any information requested by WLC. 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). 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.Guardian Name *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. Applicant Name *Address *PhonePhysician, 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. Physician InformationName *Address *Phone *Applicant InformationApplicant’s Name: *What is the applicant’s primary disability?Please list any secondary disabilities:What is the prognosis of the disability?Does the applicant’s disability affect their cognitive abilities or functioning in any capacity? Yes / No If yes, please describeDo you have any concerns about the applicant’s ability to physically tolerate the training required to work with a service dog? Yes / No If yes, please describe:Does the applicant have a history of seizures? Yes / NoDo you have any concerns about the applicant’s ability to cognitively participate in the training? Yes / No If yes, please describe:Do you have any concerns about the applicant’s ability to care for a service dog? Yes / No If yes, please describe:Why do you feel the applicant would benefit from having a service dog?Are there any additional comments you wish to make that might help us in evaluating your patient’s application for a service dog?Date *Professional Reference FormApplicant Instructions: Please provide the information requested on the first page of this form. The Professional Reference Form should then be completed by your Occupational Therapist, Physical Therapist, Rehabilitation Counselor, Psychologist or Case Worker. The completed form should be returned to WLC.Applicant NameAddressPhoneHealthcare Provider, Please release to the 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. * If the applicant is a minor, or under guardianship or conservatorship or a ward of the court, the parent or duly authorized representative is required to sign below pursuant to state and federal law. Guardian NameProfessional Reference Form To the Healthcare Provider: Please complete this form and return it to the WLC Service Dogs. 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. Provider InformationName *TitleAddressPhone *Applicant Information Applicant’s Name *What is the applicant’s primary disability?What is the prognosis of the disability?Please list any secondary disabilities:Does the applicant’s disability affect their cognitive abilities or functioning in any capacity? Yes / No If yes, please describe:Do you have any concerns about the applicant’s ability to physically tolerate the training required to work with a service dog? Yes / No If yes, please describe:Do you have any concerns about the applicant’s ability to cognitively participate in the training? Yes / No If yes, please describe:Do you have any concerns about the applicant’s ability to care for a service dog? Yes / No If yes, please describe:Why do you feel the applicant would benefit from having a service dog?Are there any additional comments you wish to make that might help us in evaluating your patient’s application for a service dog?Date *Send Message
