~Dog Owner Information~ Name: Address: City: State: Zip: Work phone: Home phone: Cell Phone: Email address: How did you hear about us?: ~Emergency Contact Information~ Name: Phone Number: Please list any additional persons who are permitted to pick up your dog(s): ~Dog Information~ Pet/Service Animal: Name: Breed: Weight: Color: Age: Male Neutered: Yes or No Female Spayed: Yes or No ~Dog Health Information~ Veterinarian Name/Clinic: Address: Phone Number: Fax Number: List any allergies or medical conditions: What form of flea & tick control does your dog use?: Please list any special instructions for your dog:

Work/Performance Task Training such as guiding an individual who is visually impaired or blind, alerting an individual who is deaf or hard of hearing, pulling a wheelchair, assisting with mobility or balance, alerting and protecting an individual who is having a seizure, retrieving objects, alerting an individual to the presence of allergens, providing physical support and assistance with balance and stability to an individual with a mobility disability, helping an individual with a psychiatric or neurological disability by preventing or interrupting impulsive or destructive behaviors, reminding an individual with mental illness to take prescribed medications, calming an individual with posttraumatic stress disorder during an anxiety attack, or doing other specific work or performing other special tasks.