Committed Canine Application For Course Participation


Please fill out the form with the greatest detail available.  This application does not bind you into any agreement or requirement to participate in the Committed Canine program.  It is used to assess whether you and the dog herein described have a high probability of success in this, specific training program.

  1. Please provide the following contact information:

    Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Cell Phone
    Home Phone
    E-mail
    Repeat E-mail:
  2. Please identify and describe your dog (if you don't have a dog, type "None" in Name Box.

    If you would like to be considered for one of the Available Dogs on our site, do so in the "Available Dog Name" box:

    Dog's Name
    Age
    Sex Male Female
    Breed:
    "Certifications" such as CGC, TDI
    "Available Dog" Name:

     

  3. I have read and understand the Pre-Application information on the website:

    NO
    YES

  4. I have an ADA recognized disability:

    NO
    YES

  5. I feel that I am capable to train my own Service Dog under the guidance of professional trainers:

    NO
    YES

  6. I believe that the dog I have chosen has the ability to become a competent Service Dog:

    NO
    YES

  7. Please describe your history with Service Dogs:

    I currently have a functioning Service Dog
    I currently have a retired Service Dog
    I do not currently have a Service Dog

  8. I need a Service Dog to assist me with:

    Mobility (balance, walking)
    Mobility (pulling a wheel chair)
    Retrieving objects
    A psychological disability (PTSD, panic disorder etc...)

    Alert (Seizure/Medical Problems)
    Emotional Support
    Hearing disability

  9. I am able to travel to Brownstown, Illinois to participate in a two day training session, twice across a period of 4-12 weeks:

    NO
    YES

  10. I have trained a dog before:

    No - not even a pet
    Yes, over 5 years ago, but not a Service Dog
    Yes, in the last 5 years, but not a Service Dog
    A Service Dog that I used or still use

  11. I need help training my dog to (choose all that apply):

    Stop jumping up                              Stop barking                               Stop nipping                                Stop going after food                       
    Walk on loose lead                          Sit / down /stay (no distractions)     Sit / down / stay (with distractions)  Come  (no distractions)         
    Come  (with distractions)         Retrieving objects                             Pulling my wheelchair                          Opening drawers / cabinets                   
    Standing to brace me                           Walking and bracing me                         Carrying objects for me in pack                
  12. Select any of the following options that apply:

    My dog needs basic training
    My dog works well for me at home, not in public
    My dog works well at home and in public

  13. Please use this box to describe, in detail, the disabilities which you need to mitigate with the use of a Service Dog:


  14. Please use this box to describe three or more specific tasks that you want to train your dog to perform:


  15. Use this box to describe your assessment of your dog's current abilities, in detail, and why you think this is a good candidate for your Service Dog:


  16. Use this box to add any other comments or concerns:



T. Rogers.
Copyright 2008 [DarnFar Ranch]. All rights reserved.
Revised: 03/24/11