Journey Together Service Dog Inc. Secondary Application

Journey Together Service Dog Inc. Secondary Application

This is the secondary application for a PTSD service dog through

Journey Together Service Dog Inc.This information in addition to personal interviews

will guide us through the stepstowards eligibilityfor a dog. All applicants will be

considered regardless of race, sex, religion,creed, sexual orientation and ethnic origin.

This program is designed specifically for individuals that have been diagnosed with PTSD.

Please fill out the entire application. We realize some of the information was also

requested on the Preliminary Application but we need to be certain that we have your

most current information.

Applicant Information

Full Name:
Date of Birth: / Gender: / Male / Female
Home Phone: / Cell Phone:
Work Phone: / E-Mail Address:
Street Address: / Apt/Unit #
City: / State: / Zip Code:

Employment Information

Name of Employer:
Address:
Name of Supervisor: / Phone:
How long have you been employed here?
Currently Employed: / Full Time / Part Time / Hours/Week
Describe your work activities to help us understand what a service dog would encounter in this
environment.
Source(s) of Income: / Employment / Social Security / Disability
Other:

Emergency Contact

Nearest Relative: / Relationship:
Street Address: / Unit/Apt #
City: / State: / Zip Code:
Home Phone: / Cell Phone:

Household Information

Please list names and ages of people living in your home

Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Name: / Age: / Allergies to Dogs?
Have all the members of the household agreed to have a service dog in the home? / Yes No
Do all members of the household agree to help care for the service dog if needed? / Yes No
Who will be the primary person responsible for your service dog?
Are you willing to take responsibility for a dog for the next 10 years or more? / Yes No
Do you understand that you will be responsible for the cost of caring for a service dog which is roughly estimated to be $2,500 per year? / Yes No
Do you / Own / Rent / How long have you lived at this address?
House / Condo / Townhouse / Apartment / Mobile Home

If you rent, please list the needed information so that we may contact your landlord.

Landlord’s Name: / Phone:
Address:
Do you anticipate a move within the next few years? / Yes / No
Do you have a completely fenced yard? / Yes / No
If yes, what type of fence? / Wood / Chain Link / Electric Fence / Height
If no, or it is not completely fenced, how will you contain a service dog on your property?
Is there a pool? / Yes / No
Have you checked your yard for dangerous objects or plants? / Yes / No

Results:

Are there distractions outside your yard?

Neighboring Dog / Loose Dogs / Busy Street / Children / Other

If Other was checked, please explain:

Physical Abilities and Equipment Required

Do you use any equipment for mobility? / Walker / Wheelchair / Braces / Other

If Other was checked, please specify:

Rate your physical strength on a scale of 1 to 10:(1 = Least and 10 = Most)

Right Hand / Left Hand / Right Arm / Left Arm
Right Leg / Left Leg / Upper Body
If you are physically disabled, at what age did the disability occur?
Is the disability progressive? / Yes / No
Are there significant secondary disabilities? / Yes / No / If yes, please describe:

Pet Information

Do you CURRENTLY own any pets? If yes, please list them here:

Name:
Species/Breed:
Age:
Male/Female:
Neutered, Spayed or Intact
Dominant/Submissive
Gets along with dogs, cats, children, etc?
Any behavior issues?
How long have you had this pet?
Where is this pet kept during the day & night?

Are you able to meet the needs of a dog in terms of regular veterinary care, heart worm and external parasite prevention, feeding high quality dog food, treats, grooming, exercise, play, training and yard clean up? Will you need assistance, either physically or financially, and if so, who will provide the assistance?

How would you give a service dog exercise and play?

Veterinary Information

Please list any veterinary reference(s). Include current and previously used veterinarians for your current pets. You need to call your veterinarian and inform them that we will be calling to check on your pet’s records.

If you currently do not have a vet, please list the vet you plan to use for your new service dog.

Vet’s Name / Clinic Name / Address including city, state and zip code / Phone number and
Email address
Which Vet listed above is your current Vet?
Which Vet listed above will be used for your new service dog?

Personal Interests, Skills and Activities

Please describe your basic daily schedule, activities, environments visited, how you spend your time in a typical week: (M-F may be the same, Saturday and Sunday different from weekdays)

Please add any other activities or interests, travel, hobbies, recreational activities you enjoy.

Do you foresee having your service dog accompany you in your daily activities and special events?

To what extent?

Modes of transportation used: / Car / Bus / Van / Taxi
Do you drive? / Yes / No

Please Tell Us In Your Own Words

Why do you want a service dog? What changes or benefits to your life do you foresee a service dog bringing to you?

Describe your ideal dog. (i.e. temperament, skills, activity level, size, male or female, breed preference)

Tell us how you feel towards learning about service dog handling skills, attending training classes, working with volunteers during placement and transitioning and giving the time and energy needed to create and foster a working bond with a new dog.

Please include any other information about yourself and your application for a Journey Together

Service Dog that you would like for us to know.

Agreement and Signature

I understand that application approval does not guarantee I will receive a service dog from
JTSD and that JTSD reserves the right to discontinue the training and placement at any time deemed necessary. (Yes/No)

I attest that the above statements are true and factual to the best of my knowledge. I consent to a criminal background check.

Signature: / Date:

Return Applications to:

If you have questions, please direct them to the email address above

or call us at 920-322-5532

Personal References

Please list two personal references. One reference must be a non-relative.

You may list a 3rd reference as an alternate.

Reference #1

Full Name:
Street Address:
City/State/Zip:
E-Mail Address:
Phones: / Home: / Cell: / Work:
Best time to contact them? / Best way to contact?
How long have you known them? / Years: / Months:

Reference #2

Full Name:
Street Address:
City/State/Zip:
E-Mail Address:
Phones: / Home: / Cell: / Work:
Best time to contact them? / Best way to contact?
How long have you known them? / Years: / Months:

Journey Together Service Dog Inc

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