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					Dear Applicant:


Enclosed you will find the application package that you requested from Georgia Canines
for Independence. Please return your completed application to our office at 1540 Heritage
Cove Acworth, Ga. 30102. If you need any additional information, please contact
Ramona Nichols at (404) 735-3647 or e-mail: gcidogs@aol.com. For more information,
please visit our website at gcidogs.org.



A COMPLETED APPLICATION MUST INCLUDE ALL OF THE FOLLOWING:

   A. The service dog application form, which you will complete

   B. A letter from you, which explains why you want a service dog and includes a
      short autobiography

   C. Service dog requirement agreement, which you should read thoroughly and sign

   D. The enclosed medical history form, which is to be filled out by your healthcare
      provider and returned with the other materials to GCI


Receiving an assistance dog is a serious, long-term commitment for all: for you and your
family, your dog, and for us. Any information that we may glean from the pages of your
application will help us to get to know you. Please feel free to write candidly and at
length, on as many additional pages as you may need to tell us about your hopes and
wishes, likes and dislikes, joys and frustrations, challenges and achievements. Of course,
all that you share will be held in the strictest confidence.

Once your completed application is received, we will contact you to schedule an
interview either by phone or at our training facility in Woodstock, Ga. The purpose of
this interview is to insure that we know what type of dog in terms of personality, social
level, lifestyle, and energy level is the best match for you.

If a service dog is appropriate for you, you will be placed on our waiting list.
Unfortunately, our waiting list is very long, and it will more than likely be many years
before we are able to provide you with a dog. GCI is working hard everyday to grow and
expand to reduce our long waiting list.


We are looking forward to working with you!

Ramona and Tim Nichols
PART A. APPLICATION FOR ASSISTANCE DOG


Date ____________________

Applicant’s Name________________________________________________________
Home Address___________________________________________________________
               _______________________________________________________________________
Home phone (______)_________________ Cell phone (______)_______________
Fax_______________________________ E-mail______________________________
Place of Employment_____________________________________________________
Position/Job Title___________________________________ Since________________

If applicant is a minor:
Names of parent(s)______________________or guardian_______________________
Home Address___________________________________________________________
Home phone (______)_________________ Work phone (______)_______________
Fax_______________________________ E-mail______________________________
Place of Employment_____________________________________________________
Position/Job Title___________________________________ Since________________

Name of spouse / partner__________________________________________________
Place of employment______________________________________________________
Work address_________________________________Work phone (_____)_________
Position/Job Title___________________________________ Since________________


Personal and Environmental Information:

Age_________ Gender_______ Height_______ Weight_______ Marital status_____

Living Arrangement (Please list all those living with you):

Name                             Relationship                               Age




Have you ever owned any other dogs?

Have you ever received professional dog training?         If yes, where?

Do other animals live with you or visit you frequently?
                                                                           Page 2 of 4

Does anyone in your household have concerns about having a companion/service
dog?

Are you concerned about fleas or shedding?

Is anyone in your household allergic to animals?

Housing: Home ________         Apartment________        Other (Describe) _________

Yard________       With Fence________       Without Fence________ Rent or Own?

If you rent, Landlord’s Name:_____________________________________________

Landlord’s Address: _____________________________________________________

Landlord’s Phone:_______________________________________________________


Is your Landlord aware that you plan to accept a service / seizure response dog?

Do you plan to move in the near future?

If yes, when and where do you plan to move?


Is the applicant employed?
How many hours per week do you work?
Do you plan to take your service dog to work with you?
Is your employer aware that you will receive a service dog?
How do your employer and co-workers feel about having a service dog at work?



Is the applicant enrolled in school?
If yes, what type of school: public or private? elementary, middle, high school or
college?
Would you like to take your service dog to school?
How does your school administration feel about having a service dog in classes?
                                                                              Page 3 of 4
Dog Care Information

Please check which tasks the applicant will be able to perform directly to take care
of the dog:

____ Brush hair daily               ____ Feed twice daily

____ Walk twice daily               ____ Brush dog’s teeth 3 times / week

____ Give bathroom breaks every 3-4 hours during the day

____ Trim hair if necessary         ____ Take to vet once / year for exam / shots

____ Clean ears as needed            ____ Provide fresh water daily

____ Give flea / tick medicines as needed

____ Give monthly heartworm medications

____ Transport for emergency vet care if needed


If the applicant cannot provide all of the above directly, please list each need and
who / how you will meet the need:




If necessary, GCI will pay your dog’s expenses after placement.
Are you able to financially provide for your dog’s basic needs?
Providing your dog’s basic needs including veterinarian care, vaccinations, medications,
grooming supplies, food, treats, toys, etc will cost approximately $800 each year.
                                                                            Page 4 of 4

Service Dog Matching Information

What is the primary disability?




What caused the disability and at what age?



Please list any secondary disabilities.




What tasks do you hope a service dog will assist you with? (Please list in priority
order)




For the following, circle the term from each group that best describes the dog that
would be the ideal canine partner for you:

Energetic or Calm                                            Cuddly or Independent

Quiet    or   Outgoing                                        Active or Laid back

Clingy    or Independent                                      Playful or Reserved

Easily motivated or Low energy                                Gentle or Exuberant
PART B. Please write a letter explaining why you want a service dog. In your letter
please include the following information and a brief autobiography. You may use
this sheet and/or attach additional pages if necessary.

On a scale of 1-10, please rate how active you think you are. One is defined as not
active at all, stay at home almost all the time, and very sedentary at home. Ten is
defined as extremely active, doing activities outside the home every day, and very
active all the time at home.

Please describe your activity level. What kinds of activities or organizations are you
involved in? What kind of work do you do? How often do you go out? What kinds of
things do you like to do when you go out i.e. movies, restaurants, etc? Do you travel?
How often do you travel? What kind of transportation do you use i.e. fly, drive?
PART C. SERVICE DOG REQUIREMENT AGREEMENT

The mission of Georgia Canines for Independence is to increase independence by
providing trained service dogs. Each dog has received approximately two years of
training, knows 80 commands, and will be given to you at no cost. Because GCI is
certifying your dog for public access, it is our responsibility to insure that the dog follows
public etiquette rules and is under your complete control at all times. To insure the
success of your service dog team, your safety, the dog’s safety, and the public’s safety,
you must complete certain requirements to earn your service dog.

Basic Requirements for Training
   1. You must attend a two week training camp held in Woodstock, Ga. to receive
       proper instruction on how to care for and work with your service dog. During
       camp, you will work with our trainers from 9:00 a.m. – 4:00 p.m. daily (except for
       one day off), and you will be required to complete daily reading, homework
       assignments, and quizzes.
   2. To be certified as a service dog team, you must pass a written final, an oral exam,
       and multiple dog handling tests to qualify to take your dog home with you.

Basic Dog Care Requirements
Your service dog meets the highest industry standards of training, however, he/she is still
a dog with basic care requirements for which you are responsible.
    1. You must be able to provide for the grooming needs of your dog. This means
       cleaning up after your dog daily, brushing hair daily, trimming nails every other
       week, cleaning ears as needed, trimming hair if needed, and brushing teeth 2 -3
       times each week.
    2. You must feed your dog a high quality dry dog food twice daily and provide fresh
       water daily.
    3. Your dog needs adequate attention, mental stimulation, and physical exercise.
       He/she should be walked daily and will need opportunities to go to the bathroom
       every 3-4 hours during the day.
    4. Your dog must be examined by a vet twice yearly and receive monthly heartworm
       medication and flea/tick medication.

Basic Requirements After Placement
   1. You must complete written monthly evaluations of your dog’s behavior.
   2. You must participate in training lessons given in your home on a frequent basis as
       needed.
   3. You must demonstrate an ability to maintain the highest standards of training, and
       you must comply with all GCI health and safety rules and regulations.
   4. The first year is probationary. At the end of the year, your team will be re-tested
       to determine permanent ownership.
   5. Each service dog team is tested annually to maintain public access privileges.
                                                                                 Page 2 of 2

Additional Regulations You Should Be Aware of
  1. To insure the dog’s safety, he/she is not allowed off-leash in an unsecured area.
       This means that if you do not have a fenced-in yard, your dog must be kept on a
       leash and attached to a handler anytime your dog is outside the safety of your
       home.
  2. To maintain a strong working relationship with your dog, no one (other than the
       applicant) is allowed to interact with the dog while he/she is working. A service
       dog is not a pet. He/she is a working dog provided to you as your canine partner.
       If you allow family members and/or people in public to pet your dog, the bond
       necessary for a working relationship will be compromised. Your dog will receive
       scheduled time-off periods, however, to allow the dog to play, relax, and receive
       attention from others.
  3. If the applicant is a child and you would like a service dog to accompany the
       recipient to school, there are additional requirements that must be met for the dog
       to have this type of access. Each case is decided individually, but in general, we
       do not recommend the dog attend school with a child until at least the high school
       level.
  4. GCI reserves the right to remove a service dog if the dog’s health or safety is
       compromised in any way. If at any time, you no longer wish to keep your canine
       partner, you must return the dog immediately to GCI.


_____ (Please Initial) I can provide the minimal daily care required for a dog.

_____ (Please Initial) I understand that accepting a service dog into my home means that
                   I am completely responsible for the dog’s health, safety, and behavior.

_____ (Please Initial) I understand that I am required to complete a two week training
         course and pass testing to earn the right to take a service dog home with me.

_____ (Please Initial) I understand that this application is just the first step in this
process. GCI has a long waiting list and cannot guarantee that I will receive a service
dog. Most applicants wait many years to receive a canine partner.

I have read and understand all the requirements set forth, and my signature
signifies acceptance of all terms stated.

Client (Print Name):

Client Parent / Guardian (Print Name):


Client Signature ____________________________________ Date_______________
PART D. THIS FORM IS TO BE COMPLETED BY YOUR PHYSICIAN AND
SENT TOGETHER WITH YOUR OTHER APPLICATION MATERIALS TO
GEORGIA CANINES FOR INDEPENDENCE.

APPLICANT MEDICAL EVALUATION FORM:
Information release:
Name of healthcare provider ______________________________________
Please release the requested medical information regarding my condition to Georgia
Canines for Independence. This information will be used to help determine my abilities
as regards to placement of an assistance dog.

Applicant’s Name (please print) ____________________________________

Applicant’s signature _____________________________________Date____________


Doctor’s Name: __________________________________________________________

Type of Practice: _________________________________________________________

Address: ________________________________________________________________

City: _________________________ State: _____________ Zip: __________________

Phone: ______________________________ Fax: _____________________________

Patient Information:

What is this patient’s primary disability? ______________________________________
_____________________________________________________________________________________



What is the cause of this disability? __________________________________________


Are there significant secondary disabilities? ____________________________________




At what age was he/she disabled? ________ Is this disability progressive? ( ) Yes ( ) No


Is there an incapacity due to alcohol or drug abuse?   ( ) Yes ( ) No
The effects of his/her disability include: Please check all that apply                    Page 2 of 3

( ) Deafness       ( ) Hearing loss          ( ) Speech impairment

( ) Coordination problems            ( ) Reduced stamina          ( ) Memory loss

( ) Slowed development          ( ) Vision impairment            ( ) Muscular weakness

( ) Limited mobility        ( ) Spasticity      ( ) Other _____________________________


Does this patient have problems with: Please check all that apply

( ) Allergies      ( ) Chronic pain          ( ) Heightened emotions          ( ) Depression

( ) Skin sensitivity      ( ) Balance        ( ) Brittle bones      ( ) Heat/cold sensitivity

( ) Seizures If yes, what type and how often?__________________________________



Does this patient use any of the following aids or assisting devices?

( ) Prosthesis     ( ) Leg brace      ( ) Electric wheelchair        ( ) Manual wheelchair

( ) Wrist brace        ( ) Hearing aid   ( ) Crutch/cane         ( ) Walker

( ) Other:_______________________________________________________________


Does this patient:

( ) Drive        ( ) Travel by bus       ( ) Travel by airplane


Current number of hours of attendant care per week: _________________________


Activities of Daily Living

Is this patient:                                                                  Please circle below

    1. Able to exercise judgment and make
       decisions necessary for ADL?                                             Yes Minimally No

   2. Able to sustain an attention span?                                        Yes Minimally No
                                                                           Page 3 of 3

   3. Manifesting inappropriate behavior
      beyond his/her control                                      Yes Minimally No

   4. Able to control physical and motor
      movement sufficient to sustain ADL                         Yes Minimally No

   5. Capable of perception and memory to
      the degree necessary to sustain ADL                        Yes Minimally No

   6. Able to follow directions and learn to the
      degree necessary to sustain ADL                            Yes Minimally No

   7. Under medication which impairs physical
      or mental functioning                                      Yes Minimally No

   8. Capable of decisions concerning self and
      others’ needs and safety                                   Yes Minimally No


Can you recommend this individual for an assistance dog? ( ) Yes ( ) No

Do have any additional comments?




Do you feel Georgia Canines for Independence might benefit from a consultation with
you? ( ) Yes ( ) No



Physician’s Signature _____________________________________ Date ____________

				
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