1
Application for a
Facility Service Dog
Date: ______
Name of Facility:______
Address of facility:______
Telephone:______Website: ______
Director/ Principal of the Facility or School: ______
E-Mail of Facility Director Principal ______
Please list the person(s) in the Facility who will have responsibilitieswith the Facility Dog:
______
If the Facility is not in a city, please tell us the closest city to you and where it is.
______
Is the facility non-profit or a school? Non-profit Public School Government AgencyBusiness
What is the name/purpose of your Facility?
______
Describe the people that you serve:
Ages ______Family Income (Low, Med, High)______
%Race: Caucasian______BlackAfrican/American______Other:______
Do you serve Veterans?______
How many people do you serve each month? ______
(More information may be requested at a later date.)
How do you think a working FacilityDog will improve your outcomes?
______
______
Facilities agree to allow Service Dogs Alabamato use photos (when possible) and success stories about working with a Facility Service Dog.
Service Dogs Alabama (SDA) requires that a Staff Member of the Facility be the Guardian for the Working Dog which means that the dog will live with them and they will be the primary caregiver. We also recommend a secondary Guardian to also be trained with the dog. If the Guardian’s employment ends at that Facility for any reason within the working life of the dog, the second Guardian will become primary Guardian and a secondary Guardian will be named and trained.When the Facility Dog is retired (usually 5-7 years), ownership of the facility dog is given to the primary Guardian if the Guardian chooses.If teachers move to other counties within Alabama, they may take the Facility Dog.
Will your facility OR the Guardian Staff Member be responsible for
◊ food ◊ grooming expenses ◊ flea and heartworm prevention ◊ medical needs? ______
Guardian Staff Member Information
Name of Guardian ______
Address ______Tel. (Home, Work, Cell) ______
Marital Status: Single _____ Married _____ Divorced _____
Do you have other pets in the home? (If yes, please list type, breeds and ages, spayed or neutered)
______
If your Facility Service Dog is not compatible with one of your pets,
are you willing to re-home the pet? YES NO
Please list any concerns your family may have about caring for a Facility Service Dog:
______
A Guardian must provide a safe home environment for the dog. Are you willing to make necessary changes in your home to make it safe? YES NO
Housing: Home _____ Apartment _____ Other (Describe): ______Yard _____ With Fence _____ Without Fence _____ Electric Fence______
Please list all those living in your home with you:
NameRelationship to youAge
______
______
______
SDA Facility Dogs do not have Public Access except when training and/or when a client is in need of the support of the facility dog in a public area.
Does the Guardian agree to attend scheduled trainingsessions in Follow the Lead methods and maintenance training and evaluation of your Facility Service Dog? YES NO
Service Dogs Alabama requires Guardians of Facility Service Dogs to attend 2 training sessions the first year. In addition, they must attend the annual re-certification training weekend on the first Saturday and Sunday in August for three years, then facetime check-in each year.
The Facility to be served agrees to raise $3,000.00 for a trained Facility Dog. A Facility Dog’s value is $6,000.00, however, SDA matches any monies raised.
If the facility is a public school, the Alabama Dept. Of Education has already funded your dog.
Authorized Facility Personnel ______Date ______
Guardian ______Date ______