Round Two ESD Application

Client name

First

Last

Task: What disability-mitigating tasks do you need your service dog to perform?

Task: Which tasks are the highest priority for training?

Public Access: What public access environments do you expect your service dog to work in (stores, restaurants, medical appointments, school, workplace, etc.)?

Public Access: What are your biggest concerns or challenges with public access and handling?

Home Environment: Describe your home setting and where the dog will live and train (house/apartment, yard access, stairs, other pets, children, etc.).

Home Environment: What daily routine and working environments should we plan for (travel, commuting, quiet/active home, visitors, etc.)?

Home environment: Describe the home environment and the people living there.

Home environment: Room for visitors in the home (who visits, how often, typical routines).

Home environment: Extra animals in the home (current or expected).

Partnership Goals: What are your goals for partnership with your service dog (independence, confidence, safety, mobility, medical response, etc.)?

Partnership Goals: What would success look like at the end of training?

Contingency care: Who can safely care for the dog during hospitalization, emergencies, travel without the dog, or other disruptions? Include the person’s relationship to you and level of dog-handling experience.

In the first 12 months of partnership, what activities, routines, or responsibilities would you like to approach differently?

Over the next two to five years, what goals related to education, employment, volunteering, community participation, travel, relationships, hobbies, or independent living are important to you?

Goal / Current baseline / How the dog may assist / Other supports still needed / Evidence of progress

Partnership expectations: What do you expect will be easier, and what may become more complicated, after adding a service dog to your life?

Balanced partnership: How will you support the dog’s physical and behavioral health, provide off-duty time, recognize stress or fatigue, and maintain your own skills and supports without relying on the dog for every need?

Support Person #1 Name

Support Person #1 Relationship to applicant

Support Person #1 Email

Support Person #1 Preferred contact method

Support Person #2 Name

Support Person #2 Relationship to applicant

Support Person #2 Email

Support Person #2 Preferred contact method

Environmental exposures: Check those likely to be common.

Environmental exposures: Other

Public behavior goals: Describe the dog’s expected position and pace, settling duration, response to distractions, toileting routine, and how you will maintain effective control.

Authorization to contact: By listing the individuals above, I confirm that they have agreed to serve as support contacts, and I authorize the program to contact them regarding my application, service-dog readiness, training participation, support plan, and related follow-up. I understand that I may withdraw this authorization in writing at any time.

I agree

Applicant Acknowledgments: I understand that a service dog is individually trained to perform work or tasks related to a disability and is not guaranteed to eliminate all barriers or replace medical care, assistive technology, personal assistance, or emergency planning. I understand that public-access work requires the dog to be housebroken, under effective handler control, and able to work safely and unobtrusively; access may be limited if the dog is out of control and effective action is not taken. I understand that training and matching decisions must consider safety, task feasibility, temperament, health, humane care, and the welfare of both handler and dog. I agree to provide accurate information, participate actively in training, communicate significant changes, follow program safety and welfare policies, and maintain appropriate veterinary care. I understand that federal, state, local, housing, transportation, workplace, and school rules may differ, and the program may provide education but not legal advice.

I acknowledge