W.A.G.S.4Kids - Adoption Application

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WAGS 4 KIDS 112 E. Center St. Berea, Oh 44017

216 406 - 7656

APPLICATION FOR SERVICE DOG : PLEASE PRINT CLEARLY

CHILD (Under 16 years of age)

PARENT INFORMATION: - MOTHER
Name_____________________________ DOB: ____________Email:______________________
Address:____________________________City:_______________State:______Zip:___________

Phone: ___________________________Work: _____________________Cell: _______________
PARENT INFORMATION - FATHER
Name: _____________________________ DOB: _____________ Email: __________________
Address: _____________________________City:______________State:______Zip__________
Phone: ____________________ Work: ______________________ Cell:___________________
CHILD”S 1INFORMATION
Name: ___________________________DOB: ______________________________
Address: __________________________City: _________________ State:____ Zip: _________
Phone: _________________ Work: ______________________ Cell: ______________
Social Security #______________________________
PLEASE LIST CONTACTS OTHER THAN PARENT’S
Emergency Contact: Name: _______________________ Phone: ____________________
Alternate Contact: Name: __________________________ Phone: __________________
Physician: _________________________________ May we contact? Y / N
Address:____________________________________ Phone: ______________________
City: ______________________ State: ____________ Zip: ______________________
Insurance:
If your child has Medicaid, what is the Medicaid number: _______________________
If you have Medicaid you need to attach a prescription from your child’s doctor.
If Applicable:
Physical Therapist: ______________________________ Phone: ________________
Occupational Therapist: _________________________ Phone: _______________________
Case Manager: _____________________________ Phone:_____________________

Diagnosis (use a separate sheet of paper if more space is needed for any question)
What is the primary diagnosis? ____________________________________________________
Are there other medical problems? ________________________________________________

How does this affect their daily living skills?_________________________________________

What are their limitations? _______________________________________________________
Are there restrictions or precautions as a result of their diagnosis? ________________________
What type of medical treatment are they currently receiving? ____________________________
What medications are they taking and what are they for? ________________________________
What types of adaptive equipment does your child use (i.e. Wheelchair, hearing aid)? ______________________________________________________________________________ ______________________________________________________________________________

Employment
Are they employed or engage in volunteer activities? Y / N
Employer:__________________________________________________________________
Address: ___________________________________________________________________
City: ___________________________________ State: ___________ Zip: ____________
Phone: ______________________ May we contact? Y / N
Basic job duties: __________________________________________________________
Do they have a case with The Bureau of Vocational Rehabilitation? Y / N
If so: Counselor name: ________________________Phone: ______________________
BVR Address: ___________________________________________________________
City: ___________________________ State: _______ Zip: ____________________

Do they have a Job Coach? Y/N
If so: Name: __________________________ Phone: _____________________
Agency Name: _____________________________
Address: ____________________________________City: __________State: _____ Zip:_________
Do you have any other social services contacts for your child? Y/N
Agency: _______________________________ Contact: ___________________ Phone: __________
Address: ___________________________________ City: ___________ State: ____ Zip: _________
Agency: _______________________________ Contact: __________________ Phone: ___________
Address: ____________________________________ City: ___________ State: ____ Zip: ________

Household Information (when families are split please list primary information below and attach a separate sheet of paper with the same information if the dog would be spending any time at the other parent’s residence.)

Type of home: Apartment: Y / N House: Y / N Do you: own / rent
Do you have fenced yard? Y / N If not, do you plan to fence the Yard? Y / N
Who lives in the home?

Name Age Relationship

_______________________________________________________________________________

________________________________________________________________________________

Are there pets currently in the household? Please list type/breed of each. Are these pets spayed or neutered? Do they live in the home or outside? ________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Service Dog Information:

What type of service dog are you seeking? ________________________________________________

Is the child able to handle the dog? Y / N                                                                                               Can the child feed the dog? Y / N                                                                                                                                                           Can they participate in grooming the dog?    Y / N                                                                                            If you answered no to any of the above questions, who will assist them in the daily care of the dog? Please explain: __________________________________________________
What tasks do you think a service dog could do to make your child more independent? ____________________________________________________________________________
Does the child want a service dog? _________________________________________________     Why do they say they want a service dog? (If the child is old enough please record their answer to this question.)___________________________________________________________________ ______________________________________________________________________________
Do you want this dog to go to school with the child? Y / N                                                                         If so, Have discussed with teachers or school administrators? Y / N                                                        What was their response? _________________________________________________________
How will the dog be of benefit to you as a parent?______________________________________    Are their other children in the home? If so, what do they think of this child having their own dog?    It is often necessary to have the child be the primary caregiver or the only one to give the dog attention, treats, and play with the dog. Are you prepared to deal with this? ________________________________________________________________________________________________________________________________________________________Is there anything else that you want us to know? ____________________________________

___________________________________________________________________________

If the child is old enough to share their own idea, express their feelings about a service dog please ask them to tell you anything else they want us to know. If the child is old enough, able to write to us, about their desire to have a service dog, please attach their letter to this application. Younger children can be encouraged to send a picture showing their new dog and how it will help them. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

References: You must have two people not related to you, complete and mail the enclosed reference letters to our office. WAGS 4 KIDS reserves the right to deny services to any applicant who doesn’t meet the criteria necessary for placement of a service dog or who requires services not trained within the guidelines of the organization. It is understood and agreed to that placement of an animal will require the fulfillment of an agreed upon fundraising partnership contract.

Parent Signature: _______________________________________ Date: _____________________ Print Name: ___________________________________________

Please fill out this next form and send it along with the confirmation of disability form to your doctor. Please ask the doctor to mail the completed form back to us. This allows for medical confirmation of disability as well as pertinent medical opinion.

RELEASE OF INFORMATION

I,______________________ do consent and request you to supply Working Animals Giving Service for Kids any medical and social information which you may have, that is based upon your knowledge of me or my child.
This information is part of the necessary data to complete my application for a Service or Skilled Companion animal and to have that animal trained and certified by WAGS 4 KIDS
This will enable WAGS 4 KIDS to understand my request for this animal and help them evaluate my child’s eligibility for their services. Any copy of this form and signature may be used as an original for release of information.

Signature:________________________________________________________
Print Name:_________________________________ Date: ________________ Address: ________________________________________________________ City: _________________________________ State: _______ Zip: __________

If applicant is a child:
Parent or Legal Guardian Signature: __________________________________________
Print Name: ___________________________________ Date: _____________________
Address: ________________________________________________________________ City: ____________________________________ State: _______ Zip: _____________

CONFIRMATION OF DISABILITY AND
APPLICANT HEALTH FORM - CHILD

Applicant:_____________________________________________

The applicant above has applied for a service dog to assist them in obtaining a higher level of independence and/or emotional stability in regards to any limitations their disability has created. Our agency is a nonprofit organization that trains and places service and skilled companion animals that assist with mobility impairment, life crises medical conditions, mental health issues, and developmental disabilities. We do not train or place dogs that would assist with any type of visual impairment. Please use additional pages to answer questions as completely as possible.
Given the list of services the dogs can perform do you think that a dog could be beneficial to the applicant? Y / N Which of the types of assistance listed would be best for this applicant? ___________________________________________________________________________

If this applicant has physical disabilities or conditions that affect and/or limit them physically, what are they and how do they affect the applicant. ___________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Does this applicant’s physical disability affect their mental or cognitive condition? For example: memory, retention, concentration, or understanding? If so, please explain in as much detail as possible.______________________________________________________________ ____________________________________________________________________________
____________________________________________________________________________

Does this person have a stress related or mental health disability? Y / N If so, please list
the diagnosis and explain how it affects the applicant.______________________________ _________________________________________________________________________
Does the child have a disability in which they lose control and might injure a dog or provoke the dog into defending itself? Y / N

In your professional opinion is it safe to place a dog with this child? Y / N Please take into account the safety of the child and the dog. Please explain in further detail if you have concerns about the placement of a dog with this child. ________________________________________ ____________________________________________________________________________
Are there any special considerations or symptoms we should be aware of? Do you have any further comments? ____________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Physician completing form (please print clearly): ____________________________________
Medical facility: ________________________ Address:_______________________________
City: ______________________ State: ______ Zip: _________ Phone: __________________
Physician signature: ________________________________ Date: ___________________

Thank you for your time in filling out this report. Please mail it to the address below. We cannot process the application and provide services without this information. PLEASE ATTACH RX
WAGS 4 KIDS. 112 E. Center St. Berea Ohio 44017

We need two letters of reference

LETTER OF REFERENCE
____________________is applying for a service or skilled companion dog for ____________________ through Working Animals Giving Service for Kids. Please take a moment to fill out this form and return it to WAGS 4 KIDS 112 E. Center St. Berea, OH 44017. Thank you for your timely response.

Name: _______________________________________ Phone Number: ________________________ Day/Night
Address:____________________________________City ________________ State __________ Zip _________
Relationship to the Applicant: ___________________________________________________________________________________________
How long have you known the applicant?___________________________
How long have you known the child? ______________________________
How does the disability affect the functional abilities of the child? ____________________________________ __________________________________________________________________________________________

Tell us about the child? Do you think they would benefit from the use of a service dog? Do you think they have the ability to handle the dog? If not, do the parents? Caring for a dog is a lot of work. Do you feel the child and/or parents have the ability to care for the dog? If not, do they have a support system in place that would be available on a daily- weekly basis to assist in the care of the dog? _____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
If the child/family have pets or if you have observed the child with other animals, how did they interact? If they have pets, are they well cared for? Do they live inside or outside? _____________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Additional Comments: ________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Signature: _________________________________________________Date: ________________________

Thank you for your assistance in providing this letter of reference for the applicant and their Service Dog!

Signature: _________________________________________________Date: ________________________

Thank you for your assistance in providing this letter of reference for the applicant and their Service Dog!

112 East Center St.
Berea, Oh 44017

216-406-7656