Helping is not our job. It's our passion!
We specialize in Diabetic Alert Dogs & Seizure Alert/Response Dogs
Our techniques are Patent Pending # 60/639,948

Self Training Classes Application

Please note that the submit button is at the very bottom and to the left!

Today's Date   

Applicant's Name

Address Line 1   

Address Line 2   

Home Phone #         

Work Phone #    

Email address    

Applicant's date of birth  

Male or Female? 

Name of nearest relative: 

Relationship:

Phone number(s): 

Address:

Please list any previous dog training experience you have.  Please be specific and honest.  If this dog is for a child, please list any previous dog training experience the child has as well as any the parent has.

Applicant's marital status: 

Date of diagnosis? 

Type I or type II diabetes? 




If insulin dependent, what is your method of insulin delivery (shots, pump, etc)?

Please list secondary disabilities, if any:

Are your secondary disability or disabilities progressive? 



What is your approximate height and weight?

Height

Weight

Please check the effects of your secondary disability:

Deafness   

Speech Impairment   

Reduced Stamina   

Hearing Loss  

Coordination Problems  

Limited Mobility 

Memory Loss  

Spasticity

Slowed Development    

Vision Impairment    

Muscular Weakness

 

Other: 

 

Do you have any problems with….

Allergies      

Chronic Pain       

Heightened Emotions    

Depression

Skin Sensitivity  

Balance       

Brittle Bones        

Heat/Cold Sensitivity

 

Have you experienced Diabetic seizures or coma? 



If yes, how often?

Do you use any of the following aids or assisting devices?

Prosthesis      

Leg Brace       

Electric Wheelchair     

Walker

Manual Wheelchair      

Wrist Brace     

Hearing Aid     

Crutch/Cane 

 

Other:

 

Are you active in the military, a veteran, or a dependent of an active member of the military or veteran? 



If yes, please explain. 

Primary Care Physician, PT, OT, Diabetes Team Members, and/or Other Health Professional Important to Your Care (Please list with phone numbers):

 

Housing :

House 
Apartment
Other (Describe):

 

Do you have a Yard? 

No
Yes with fence
Yes without Fence

 

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

Name Relationship Age

 Do you have an attendant? 


If this dog is for a child, please select "yes" and "Parent"   

 

Please describe your home and your neighborhood (i.e., quiet, lots of visiting children, close to retail/commercial, suburban, rural, lots of traffic, etc.):

Have you ever had a dog? 



       

Describe your experience with your dog: 

Do other animals live with you or visit you frequently? 



If so, please describe (including breed, sex & age). 

Who is responsible for the care of these animals? 

Who will assist in the daily care and training of your dog, if appropriate?

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



 

If so, please describe: 

Are you (or anyone in your household) allergic to animals? 



Are you (or anyone in your household) concerned about fleas, shedding? 



Are you currently employed or a full-time student? 



If so, do you want your dog to assist you while at work or school? 



In what way? 

Have you discussed with your employer / coworkers or teachers / students having a dog in the workplace? 



Are they supportive? 



Pick five of the following words that would best describe the dog you would like to have.

happy
sweet    
easy going    
independent    
assertive    
devoted    
submissive
friendly    
dependent   
loving    
trusting    
excitable    
communicative

Pick five of the following words that would describe traits you would not like to have in a dog.

serious
slow
playful
calm
willing
attentive  
energetic     
sensible      
responsible    
smart   
protective    
dependable    
stable    
confident 

happy
sweet
easy going
independent    
assertive    
devoted    
submissive
friendly    
dependent   
loving    
trusting
excitable    
communicative

 

Describe your means of transportation: 

 

Are you able to attend weekly classes in the evening or on weekends? 

Yes     No

 

What are your thoughts, concerns, etc. about such?

Do you realize that this is a dog with dog tendencies and dog needs…not a robot? 

What are your expectations of the dog? 

Please provide us with a short autobiography about yourself.  Parents, if the child is the applicant, you may have them tell you what to type as we would like to hear from the child, but we would also appreciate a biography from you about your child and family.  Please include child's personality traits, sports they are involved in, likes and dislikes.  We ask this information so as to better match the individual with their dog.

Autobiography from applicant:

Biography from parent about child: 

 

 

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For more program information please email or call: (573) 493-2627
108 Hwy PP, St. Elizabeth, Missouri 65075

We accept inquiry calls from 8am-10pm CST, M-F
24/7 Contact is available to our clients




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