Name
*
First Name
Last Name
Preferred Pronouns
She/Her
He/Him
They/Them
Other
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Handler Name (if different than above)
First Name
Last Name
Is the handler a minor?
*
No
Yes, 6-9 years old
Yes, 9-12 years old
Yes, 12-15 years old
Yes, 15-18 years old
Handler Disability Type(s)
*
Handler Disability Details
Please share as much as you feel comfortable. Helpful notes include: what situations are commonly difficult for you, what accommodations are most helpful, and whether your disability is stable or unpredictable.
Task List
Please check off any tasks you would like to train your dog to perform. To be considered a task, the behaviour must directly support the symptoms of your disability. NOTE: initial lessons will include discussion and brainstorming around this list - this list is not a final decision.
Do you understand the laws governing service dogs in Ontario?
*
Yes
No
Unsure
Would you like your dog to be trained in Public Access?
*
Yes
No
Unsure
What does your access and comfort with transportation look like?
*
Dog Name
*
Dog Breed
*
Dog Age/Birth Date
*
Dog Weight
*
Name of Veterinary Office
*
Date of Dog's Last Rabies Vaccine
*
MM
DD
YYYY
Dog's Sex
Male
Female
Is your dog spayed or neutered?
*
Yes - before 1 year old
Yes - after 1 year old
No - planned for the future
No - dog is staying intact
Does your dog have any physical health concerns, allergies, or previous medical history?
Has your dog attended training before? If so, what was covered?
My dog has been exposed to:
Behaviour Screening
Please check off any behaviours your dog demonstrates.
If you checked off any behaviour screening boxes, please share some details about the frequency, severity, and common environments where these behaviours occur.
Please use this space for any other comments regarding your situation or your dog's training.
I understand that Alliance Service Dogs uses positive-reinforcement based training methods and may not be able to help me if I choose to train with aversive tools.
*
Yes
No
Liability Release
*
Alliance Service Dogs will endeavour to create as safe an environment as possible for the training of my dog and will offer only sound, safe, and responsible instruction. However, to the extent that Alliance Service Dogs is insured for any unintentional or negligent errors, omissions, or incorrect assertions, Alliance Service Dogs will be responsible for any such acts or omissions, but only to the extent of such insurance.
I understand the inherent risks in owning a dog, including but not limited to the risk of dog bites to myself or others. I represent and warrant that I have provided Alliance Service Dogs with full and complete, accurate information regarding any bite history and similar incidents or hazardous tendencies of my dog, and that I will update that information if it changes. I understand that I am and will remain responsible for the actions of my dog at all times, and I hereby agree to indemnify, release, and hold harmless Alliance Service Dogs of any and all claims, whether made by myself or any third party, of injury, expense, costs, or damages caused by my dog.
I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service.
