Application

NEADS Service Dog for Classroom, Therapy or Ministry

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  = Required Information

Personal Information

First Name
Last name
Street Address
City
State
Postal Code
Phone Number
Email
Date of Birth
Month
Day
Year
In case of emergency, name of a relative we can call if we could not reach you.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone
Emergency Contact Relationship

Professional Activities

Occupation
Business Name
Business Street Address
Business City
Business State
Business Postal Code
Business Telephone
Length of current employment.
How long have you been a teacher/therapist/minister?
Describe the children and/or adults you are working with (include their disabilities and ages).
Please describe your present responsibilities with the children or adults:
Please describe the setting where you work:
Are there any other animals in your classroom, office, or building?
Have you discussed this with your employer?
Schooling Completed

Living Arrangements

Living Environment?
Please describe your neighborhood (for example, busy road, neighbors close by, dogs/cats running)
Do you live in a one level or multi level home?
Do you own or rent?
Do you live in a house or apartment ?
Do you have a yard?
How many people live with you?
Please list below name, relationship and age of people living with you:
Do you have frequent visitors?
Do you or anyone in your household have a dog now?
Please list other pets (type, age, altered, friendly to dogs?)
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