Paws As Loving Support (PALS) Assistance Dogs

Dear Service Dog Applicant,

Thank you for your interest in Paws As Loving Support Assistance Dogs’ Service PALS for children with autism and/or other disabilities.

Please take a few minutes to fill out the enclosed service dog application packet to continue the application process for your child. You will receive a decision as to your status after our application review team has reviewed your child’s completed client application packet.

Please keep a complete copy for your records.

Once again, thank you for your interest in obtaining a service dog from Paws As Loving Support Assistance Dogs for your child!

Sincerely,

Nancy Pierson President and CEO

Paws As Loving Support Assistance Dogs 7580 Covey Road Forestville, CA 95436 (707) 887-PALS(7257) Email:[email protected] “Special PALS for Special Needs” Paws As Loving Support (PALS) Assistance Dogs Service Dog Application Checklist

Mail your application package to:

Paws As Loving Support (PALS) Assistance Dogs Service Dog Application 7580 Covey Road Forestville, CA 95436

Enclose all following items in your application package. Incomplete applications will not be reviewed.

 Application – fully completed, legible and signed.

 3 Letters of Recommendation – one from a friend or family member, one from your child’s physician or therapist and one from your child’s teacher.

 Copy of your child’s most recent IEP

 Picture and/or video of your child.

 Personal Essay – If your child is able to write or dictate a one page essay, please encourage him/her to answer the following question: Why do you want a service dog? If your child would rather draw a picture, that would be fine.

 Parent’s Essay -- How will a service dog enhance or improve the quality of both your child’s and your family’s lives at home and in the community?

 Describe -- a typical week (daily-Sunday through Saturday) for your child and family when your child is attending school and one when s/he is not from the time that your child awakens till the time s/he goes to bed.

 Anything else that you would like our client application review team to know about your child.

 Non-refundable processing fee of $100.

2 Paws As Loving Support (PALS) Assistance Dogs Service Dog Application

Date ______Child’s name ______Mother’s name ______Address______Daytime phone ______Evening phone ______Cell phone ______E-mail address ______Father’s name ______Address______Daytime phone ______Evening phone ______Cell phone ______E-mail address ______With whom does the child reside ______Child’s date of birth ______Primary diagnosis ______Additional diagnoses ______Name of school ______School’s address ______School’s phone number ______1) How did you hear about PALS? ______2) Have you applied at any other service dog organizations? ______If yes, where? ______3) Why do you want one of our service dogs for your child? ______4) What are your expectations regarding the service dog’s skills? ______5) Does you child want a service dog? Why or why not? ______

3 6) Do you want a service dog to go everywhere with your child or mostly help at home & why? ______7) Does an aide assist/work with your child? At home? ______At school? ______If yes, indicate hours______days______8) List the names and specialties of any doctors, therapists and educators currently working with your child. Please include addresses and phone numbers. ______9) What does your child like to do? ______10) What are some of your child’s talents? ______11) What are some of your child’s strengths and skills? ______12) Does your child participate in sports or Special Olympics? ______If yes, what sport/s? ______13) Describe your child’s level and means of communication. ______14) How does your child show affection? ______15) Does your child: (check all that apply) _____ like animals _____ bolt _____ pull hair _____ hit _____ scream Run away from caregivers? ____ never ____ sometimes ____ frequently Demonstrate hyperactive behaviors? ____ never ____ sometimes ____ frequently Demonstrate impulsivity? ____ never ____ sometimes ____ frequently

4 Demonstrate aggressive behavior towards others? ____ never ____ sometimes ____ frequently Demonstrate aggressive behavior towards animals? ____ never ____ sometimes ____ frequently Experiences temper tantrums? ____ never ____ sometimes ____ frequently Experience a very short attention span? ____ never ____ sometimes ____ frequently Experience oversensitivity to sound? ____ never ____ sometimes ____ frequently Experience oversensitivity to being touched? ___ never ____ sometimes ____ frequently Experience an exaggerated reaction to light, odors or other stimuli? ____ never ____ yes If yes, please identify which stimuli and frequency of reaction: ______Demonstrate abnormal moods, including giggling or weeping for no apparent reason? ____ never ____ sometimes ____ frequently Demonstrate a lack of fear to real dangers (age appropriate)? ____ never ____ sometimes ____ frequently Experience difficulty in forming peer friendships? ____ never ____ sometimes ____ frequently Experience seizures? ____ never ____ yes – if yes, describe type and frequency: ______Demonstrate repetitive use of language or movements? ____never ____ yes – If yes, please describe: ______Demonstrate a lack of social or emotional exchange? ____ never ____ sometimes ____ frequently Demonstrate frustration/irritability with minimal changes in routine? ____ no ____ mild _____ moderate ____ severe Take medication? ____ yes ____ no If yes list names of meds: ______16) What are the most difficult behaviors your child exhibits? ______17) What triggers these behaviors? ______

5 18) What does your child like to do? ______19) Is there anything else that you feel we should know about you child? ______

20) What type of residence do you have? [ ] House [ ] Townhouse [ ] Apartment [ ] Duplex [ ] Condo 21) Do you have a fenced yard? [ ] Yes [ ] No If yes, what type of fence do you have? ______Height? _____ 22) Please list all the members of your household and their ages: ______23) Do any of these individuals have special disability and/or medical conditions that could be affected by having a service dog in the home? If so, please explain: ______24) Have you ever owned a dog? [ ] Yes [ ] No Breed/s? ______When? ______25) Please list all pets in your household along with their ages and whether or not they’ve been spayed or neutered. ______26) How do they get along with other dogs? ______27) Can you provide proof of vaccinations for your pets? [ ] Yes [ ] No 28) Please provide the name, address and phone number of your veterinarian. Name: ______Address: ______Phone: ______29) What do you estimate it will cost to care for a service dog each year? $ ______(Food, grooming, equipment, veterinary care, vaccinations, etc.) 30) Are you willing to take responsibility for a dog for the rest of his/her life, possibly 10 years or more? [ ] Yes [ ] No

6 31) Do you consent to a visit to your home from a PALS representative? [ ] Yes [ ] No

32) If we can’t come to your home due to distance, will you provide: a) a video of your home, yard, family members and animals? [ ] Yes [ ] No b) three references that we can contact? [ ] Yes [ ] No 33) Are you willing to come to PALS to pick up your new dog? [ ] Yes [ ] No 34) Best day and time to call to set up a telephone interview. ______35) Best day and time for an in-home family interview. ______

As parent/guardian of ______, I give Paws As Loving Support Assistance Dogs my permission to obtain any and all information deemed necessary from any or all of the professionals listed in question #7. This information will be used to help determine my child’s eligibility for and need of a service dog from PALS. Parent/guardian signature: ______Date: ______

To be completed by PALS staff Telephone interview Date: ______Time: ______Staff: ______Comments: ______In-home family interview Date: ______Time: ______Staff: ______Comments: ______Approved ____ Date: ______Declined ____ Date: ______Reason/s: ______Reviewed by: ______Title: ______

Paws As Loving Support (PALS) Assistance Dogs 7580 Covey Road Forestville, CA 95436 (707) 887-PALS (7257) (707) 887-7257 fax www.PawsAsLovingSupport.org 7 Service Dog Team

Media Authorization and Release

Subject to the terms and conditions set forth herein this Agreement, I ______do hereby irrevocably authorize Paws As Loving Support (PALS) Assistance Dogs, its successors and assigns and those acting under its permission on its authority, to copyright use, and publish, for art, sales materials, advertising promotion, packaging, trade or any other lawful purpose whatsoever, articles written or comments made by me as well as photographs, pictures, portraits or images, of me and/or my dog/s, or in which I/we may be included in whole or in part, or composite or distorted in character, or form, in conjunction with my/our own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium. Any and all comments made by me are provided to Paws As Loving Support (PALS) Assistance Dogs, without receipt of any promise of consideration. The undersigned warrants that he/she has the full power and authority to grant all of the rights conveyed hereunder and hereby waives any right that he/she may have to inspect or approve the finished product or the advertising or other copy that may be used in connection therewith or the use to which it may be applied. The undersigned further agrees that this authorization and release shall be binding upon his/her heirs, executors, administrators, successors and assigns. The undersigned warrants that all comments made by me will accurately reflect the opinions and experiences of the undersigned and that the comments are true and correct to the best of the undersigned's knowledge and belief. The undersigned further warrants that he/she is of full age and has every right to contract in his/her own name in the above regard and further that he/she has read the above authorization and release, prior to it's execution, and that he/she is fully familiar with the contents thereof.

Child’s Name: ______

Permission to photograph entire family ___Yes ___ No

Parent/Guardian Signature: ______Date: ______

8 Service Dog Team

Release from Liability

I ______(please print) indemnify and hold Paws As Loving Support (PALS) Assistance Dogs harmless from and against all claims, losses, and/or liabilities for damage done by my child’s service dog in training/service dog to any person, dog or property. I indemnify and hold Paws As Loving Support (PALS) Assistance Dogs harmless from and against all governmental charges or fines and attorney’s fees arising out of the acts or omissions of Paws As Loving Support (PALS) Assistance Dogs, including but not limited to interactions with instructors, volunteers, attendees, or other attendee’s dogs involved in training my child’s service dog in training/service dog during team training, workshops, seminars, meetings, or any gatherings sponsored by or conducted by Paws As Loving Support (PALS) Assistance Dogs. I further indemnify and hold Paws As Loving Support (PALS) Assistance Dogs harmless if any injury is incurred by me or my dog in any of the above venues, demonstrations involving my child’s service dog in training/service dog, or transportation of said dog to or from the training site, within the training site or event.

Signature: ______Date: ______