Please provide the following contact information:

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:

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

NO
YES

I have an ADA recognized disability:

NO
YES

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

NO
YES

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

NO
YES

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

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

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

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

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                

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

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

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

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:

Use this box to add any other comments or concerns: