Pre Application Form

 

Thank you for your interest in applying for an Assistance Dog.  Canine Helpers trains Service Dogs and Therapy Dogs to assist people with a disability.  Please confirm that you meet the required eligibility criteria, then scan and email this form to This email address is being protected from spambots. You need JavaScript enabled to view it. or mail the form to: Canine Helpers for the Disabled Inc.,  PO Box 956,  Caboolture  Qld  4510 

  • I have a disability;
  • I can effectively communicate with, instruct and independently exercise a dog, or have a responsible carer to help with maintaining a dog;
  • I am able and willing to pay for food, veterinary and all other expenses for the life of a dog;
  • I have no other dogs in my home;
  • I have a fully fenced and gated yard.

If you meet ALL eligibility criteria, please complete the questions below to give us a better understanding of your details and your needs.  Applications will be followed up by a telephone interview.

 

Contact Details

 

Name:………………………………………………………………………………………………….

 

Address:……………………………………………………………………………………………….

 

City/Postcode:………………………………………………………………………………………

 

Contact Number:………………………………….Work Number:………………………………

 

Email:………………………………………………………………………………………………….

 

Date of Birth:…………………………………………………………………………………………

 

Type of Accommodation: (Please Tick)

 

House:.............. Apartment:.................Group Housing:...................Other:......................                      

 

How many people live in the accommodation with you?…………………………………………

 

Describe your medical condition:……………………………………………………………………

 

When was your medical condition diagnosed?……………………………………………………

 

Do you have any secondary health problems?  If so, please describe:……………………………

 

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Applicant’s Signature:……………………………………………Date:……………………………