Assistance Dog United Campaign
Assistance Dog Provider Application

 
  Organization Information

Program Name: ______________________________________ Abbreviaton: ___________

Address: __________________________________________________________________

City: ___________________________________ State: ___________ Zip: _____________

Telephone: __________________ TDD: _________________ Fax: ___________________

Website: ____________________________________ Email address: _________________
 
 

       
Program Information (check all that apply)
1. We train Assistance Dogs
   Owned by our assistance dog applicants that
     Live with the applicant during the ____ weeks of training.
     Are boarded at our facility during the ____ weeks of training.
     Live with a foster family during the ____ weeks of training.
     Live with a vounteer/paid (circle one) trainer during the ____ weeks of training.
     Other: __________________________
   That we acquire from
     Our own breeding program.
     Donations of pure breed puppies.
     Donations of pure breed adults.
     Donations of mixed breed puppies.
     Donations of mixed breed adults.
     Shelters/pounds/humane societies.
     Breed rescue organizations.
     Other: __________________________
 
2. Puppies that we acquire are raised by
   Foster families.
   Assistance dog applicants.
   Other: __________________________
 
3. Vet, food and other costs incurred during the dog's training
   Are the responsibility of and paid for by the assistance dog applicant.
   Are the responsibility of and paid for by our program.
   Other: __________________________
 
4. We teach assistance dog applicants
   To train their own dogs (or dogs we acquire for them) by attending
     Group instructional classes at our facility and surroundings.
     Private instruction at our facility and surroundings.
     Private instruction at their home and surroundings.
     Other: __________________________
   To work the dogs that we have acquired and trained by attending
     Group instructional classes at our facility and surroundings.
     Private instruction at our facility and surroundings.
     Private instruction at their home and surroundings.
     Other: __________________________
   To work their own dogs that we previously trained by attending
     Group instructional classes at our facility and surroundings.
     Private instruction at our facility and surroundings.
     Private instruction at their home and surroundings.
     Other: __________________________
   To use their dogs in animal assisted activities and therapy.
 
5. For the ____ days of our assistance dog applicant instruction,
   The applicant is required to travel to and reside at our training site,
     The applicant pays for  travel,  lodging,  food expenses.
     Our program pays for  travel,  lodging,  food expenses.
     Other: __________________________
   The trainer is required to travel to and reside at the applicant's locale,
     The applicant pays for the trainer's  travel,  lodging,  food expenses.
     Our program pays for the trainer's  travel,  lodging,  food expenses.
     Other: __________________________
 
6. We train or facilitate the following types of assistance dogs
   Service  Hearing  Guide  Social/therapy  Other: ______________
7. The number of successful assistance dogs we have placed is the following
  ___ Service ___ Hearing ___ Guide ___ Social/therapy
___ Other: ______________
 


 
We do hereby request membership in the Assistance Dog United Campaign and certify the
above information to be true and correct.

This application must be accompanied by your 501(c)(3) determination, audits and 990's (or tax returns) for the last two fiscal years,
together with program placement information, unless this is a new program. If you are not required to submit federal
and state returns, submit a statement of income and expenses. Please submit samples of your program marketing materials for our files.


First Name: ________________ Last Name: ________________ Title: ________________

Signature: ______________________________________ Date: ___________________