9440 Science Center Drive, New Hope, MN 55428 p. 763.331.3000 | f. 763.331.3009 | info@can-do-canines.org | www.can-do-canines.org
Hello!
Thank you for your interest in applying for a Mobility Assist Dog from Can Do Canines. We train
assistance dogs to help clients maintain and increase their independence. Training is provided free of
charge to qualified applicants. In order to be considered for the Mobility Assist Dog program,
applicants must meet the following criteria:
• Must be a resident of Minnesota or Wisconsin.
• Must have a physical disability, debilitating chronic illness or neurological disorder.
• Must be physically and financially able to take full responsibility for the dog after certification.
• Must be at least 10 years old.
• The assistance dog must be the only dog in the home, unless it can be demonstrated that the dogs
in the home will not interfere with the work of the assistance dog.
Please complete the following forms and return to me:
1. $50 Non-refundable application fee
2. Signature portion of “Is a Service Dog Right For You?”
3. Part I General Information
4. Part II Service Dog Applicant Information
5. Medical Release and Reference Form
After I receive your application with the items listed above, I will request references from your
professional and personal contacts. Your personal contacts should be someone like a friend, or a
coworker that you have known at least a year, but not a family member or someone who lives with you.
To help keep the application process on track, I recommend you contact the people you listed as
references so they know to expect a letter from us.
When your file is complete, training staff will review your application. After this preliminary review,
you may be contacted for an interview. We work with individuals on a first come, first served basis, so
please be patient. Again, thank you for applying to Can Do Canines!
Sincerely,
Cari Bishop
Program Assistant
Can Do Canines
9440 Science Center Drive
New Hope, MN 55428
763
-331-3000 office ● 763-331-3009 fax
info@can
-do-canines.org
What are the steps to get an assistance dog?
Answers to this and other questions you may have about our Assistance Dogs
W
e are asked a lot of questions about the particulars of getting an assistance dog. We thought it might be helpful to
highlight some of the key steps.
• T
he first step is to request an application from us by phone or email. Complete the application forms and return them
to us with the application fee. Once we have received the required forms from you and your references, your
application will be reviewed by training staff.
• A
fter the preliminary review of your application, you may be contacted for an in-home interview. During this
interview our training staff will answer any questions you might have, and will check your home for its safety and
su
itability as a new home for an assistance dog. Completing the application process does not guarantee acceptance
into the program.
• N
ext, if your application is accepted, our training staff will begin looking for a dog for you that will meet your needs
.
B
reeders or animal shelters donate some assistance dogs to us as adults, but most are raised as puppies by volunteer
Puppy Raisers. During months of training in their homes, Puppy Raisers prepare the dogs to be well-behaved partners.
R
egardless of how a dog comes to us, each one goes through many hours of training at our facility and in public
settings.
• T
he training staff will select a dog they feel is best suited for you. You’ll be invited to meet the dog, often at our
training facility. If you agree that this is the right dog for you, we will continue with any special training the dog may
need in order to serve your particular needs. After the dog is trained, we start working with you and your dog together,
as a
team. You’ll receive a manual to guide you with both the training and care of your dog. In addition, our staff
works closely with you to teach you the necessary commands and how to handle the dog properly. At first you’ll be
working at our training center (or, in some cases, at your home). Once you’re in good control of the dog, you’ll begin
g
oing out in public together to practice your skills in real-life situations—including distractions. After a while, the dog
will spend the night at your home to see if you’re ready to work together even more closely. Eventually, the dog w
ill
m
ove in to your home, and training continues as you have more time to practice together
.
• Wh
en your training as a team is complete, you’ll take two certification tests. One test demonstrates all of the task
s
y
our dog was trained to perform for you and the other test rates your control over your dog in public settings. Whe
n
your dog passes both tests it is considered a “Certified Assistance Dog” and your meetings with our trainer will come
t
o an end. You’ll continue practicing with your dog on a regular basis to maintain the skills and good habits you’ve
worked so hard to build.
• A
fter certification, we will print a picture of you and your dog in our newsletter, Tails to You, along with a story about
your experience with your new dog. You’ll receive an identification card and be scheduled to attend the next public
graduation ceremony (held in February, June, and October). You and your dog will be properly honored as the special
team you’ve become. You’re encouraged to invite your family and friends to help you celebrate this very special day
as you receive a diploma and your dog receives a graduate identification cape and a canine-style diploma! After
graduation, you and your dog are finally on your own, but Can Do Canine’s advice and support remain only a phone
call or email away.
What options do I have if I want to train my pet dog to be an assistance dog?
If you want your own pet dog trained as an assistance dog, you and your dog will have to meet certain requirements.
Among others, you must already have done some training with your dog, and your dog must meet the same age and
medical requirements as a dog provided by Can Do Canines. You should know that most pet dogs do not meet all these
requirements. We provide this option because, whenever possible, we want to keep people and their much-loved pets
together. Please contact our office and ask for our Assistance Dog/Owner Trained criteria.
Can Do Canines
9440 Science Center Drive
New Hope, MN 55428
763
-331-3000 office ● 763-331-3009 fax
info@can
-do-canines.org
Is An Assistance Dog Right For You?
Dogs are very special animals. They are highly social animals and need close “family” relationships just as much
as they need food, shelter and proper exercise. Like people, each dog is unique with its very own personality,
feelings and needs. They are not like people who can understand why something happens or doesn’t happen;
therefore, it is essential that their owners assume responsibility for their care and their needs. In return, dogs
will be eager to please and serve their owners.
It is most important that the relationship between you and a service dog be one of mutual caring and support.
Building a close working relationship will take time. When the dog is teamed with you, it will have changed
homes and “families” two or three times from its birth. It will have gone through several different training
environments. It will need a period to adjust as it shifts its allegiance from its previous trainer to you. It will
need to learn to trust and respect you as the new leader of its extended “family.” This period will be a period of
confusion for the dog and you will need to be patient and supportive while it makes the transition.
The dog will not be the only one who will be making a big transition. You will have some major adjustments to
make in your life as well. The dog’s arrival will be similar to adding a new family member. Routines must be
changed and priorities rearranged. A dog has natural canine needs that must be met at appropriate times
whether it is convenient for you or not. If you are unable to meet its needs yourself, you will still be responsible
for making sure that SOMEONE takes care of the dog. Even though the dog will be highly trained by the time
it is transferred to you, incidents such as unwanted elimination, chewing, barking or vomiting may occur as a
result of stress, illness or extreme changes in routine. Unpleasant though such incidents are, immediate clean up
is necessary. Housecleaning chores also will increase to cope with the dog hair, tracked-in dirt, etc.
Once the transfer is complete, YOU will be responsible for continuing the training exercises and reinforcing the
dog appropriately for doing its tasks well. Staff is always available for follow-up training. It is most important
that you consider carefully whether you have the time and energy and are willing to make the commitment
necessary to have an assistance dog.
If you do decide that you have the time, energy and commitment and, above all, the desire to maintain your
independence, take some time to think about what it is you want a dog to do for you. List some specific tasks
you would like a dog to do such as retrieve things for you, turn lights off and on, or open and close doors. Don’t
worry at this point whether or not a dog is capable of doing the tasks, just let us know what you would really
like help with. Our staff will assess if it is possible to train a dog to do the task. Safety for both you and the dog
is a major consideration in making an appropriate team match. It is very important to find out as much as
possible about you in order to make the best match possible.
Completion of the application process does not guarantee that you will be matched with a dog.
If you are
accepted into the program, you will be supplied with the education and training that you will need to assure that
the dog is cared for appropriately and that you have the skills to work with and use the dog in the best possible
way. Can Do Canines will maintain ongoing contact with you and your dog. It is very important to us that you
and your dog are a successful working team. You will be an “ambassador” for Can Do Canines. However, no
applicant, client or graduate shall be required to participate in fund raising or public relations activities without
their expressed and voluntary permission. We want you to be pleased with your Service Dog and pleased with
Can Do Canines, and we want the dog to be a well cared for and devoted worker.
PLEASE SIGN – CUT AND RETURN THIS PORTION WITH YOUR APPLICATION
I have received and read
Is An Assistance Dog Right For You?
Signature Date
Page 1 of 2
Please use additional paper if needed.
Can Do Canines – Assistance Dog Application
Part I – General Information
Name Home Phone □ Voice □ VP
Address Work Phone □ Voice □ VP
City, ST, Zip Cell Phone □ I am a Veteran of
the Armed Forces
County Date of Birth
Emergency Contact – Name Your Email
Emergency Contact – Phone Gender □ Male □ Female
How long have you lived at your current address? Occupation
Have you ever applied or are you applying to other □ Yes □ No Employer
assistance dog organizations? If yes, please list. □ Full-time □ Part-time □ Not employed
Annual household income $
Have you ever been convicted of a crime or □ Yes □ No (all individuals combined)
misdemeanor? If yes, please explain. How many people live with you?
Fill in their information below.
Name Relationship Age
Do you rent or own your home? □ Rent □ Own
If you rent, does your landlord know that □ Yes □ No
you are applying for an assistance dog?
Are you normally allowed to have pets where □ Yes □ No
you live?
Do you plan to move in the future? If yes,
□ Yes □ No Is anyone else living in your home □ Yes □ No
when and where? deaf, hard of hearing or disabled?
If yes, list who and explain.
Describe your home and yard.
Please provide the names and numbers for:
Name Phone May we contact?
Medical Professional □ Yes □ No
Mental Health Professional □ Yes □ No
Social/Case Worker □ Yes □ No
How many time have you been hospitalized in the last 2 years? Explain any medical treatment you received in the
last year.
How long were you in the hospital each time?
Do you have an ongoing physical or mental illness? □ Yes □ No Are you allergic to dogs? □ Yes □ No
Are you under the care of a medical or □ Yes □ No Is anyone living in your home □ Yes □ No
mental health professional? allergic to dogs? If yes, list who.
Are you under the care of a social/case worker? □ Yes □ No
If yes, how does this person assist you? Do you have any type of learning □ Yes □ No
disability? If yes, please describe.
Page 2 of 2
Age Breed
Do you own dog(s) now? If yes, fill in age and
□ Yes □ No
breed information.
Do you hope to train your pet dog to help you? □ Yes □ No
If yes, which one?
Number Age Type of other pet(s)
Do you have any other pets? If yes, fill in □ Yes □ No
Number, age and type
Do you think you are knowledgeable about □ Yes □ No
dog care and behavior? If yes, please explain.
Describe any particular traits that you like or dislike in a dog.
Monthly Cost Yearly Cost
How much do you think it costs to care for an assistance dog?
$ $
Can you afford to pay these costs? □ Yes □ No
An assistance dog needs daily training, attention, love and care.
Do you have time to spend with a dog?
□ Yes □ No Will your assistance dog accompany □ Yes □ No
you to work?
Are you able to exercise the dog?
□ Yes □ No Will your assistance dog accompany □ Yes □ No
you on vacation?
Are you able to take the dog to the veterinarian?
□ Yes □ No How many hours a day will your
Assistance dog be alone? hrs/day
Are you able to groom the dog? □ Yes □ No
Are you able to clean up after the dog goes to
□ Yes □ No
the bathroom?
Print the name of the person filling out the application, if other than applicant, and their relationship to applicant.
Name Relationship to Applicant
The signature below serves as evidence that the individual (applicant), parent or guardian has supplied the information and,
to the best of their knowledge, it is up-to-date and accurate.
Signature Date
Can Do Canines
9440 Science Center Drive
New Hope, Minnesota 55428
phone 763-331-3000 fax 763-331-3009
info@can-do-canines.org
Page 1 of 2
Can Do Canines – Assistance Dog Application
Part II – Mobility Assist / Diabetic Assist / Seizure Response
Applicant Name Date
You are applying for an assistance dog. Please explain how you think this kind of dog will help you. Include as much
information as possible as it is important that we understand what you want from an assistance dog. Use additional pages
if necessary. Please Print Clearly.
The goal of all assistance dogs is to improve a person’s quality of life and help them live more independently.
- A Hearing Assist Dog alerts someone who is deaf or hard of hearing to sounds that happen in their environment.
- A Mobility Assist Dog helps a person who is physically disabled perform routine tasks such as picking up and
carrying objects, opening doors, and pulling wheel chairs.
- A Special Skills Dog helps someone who is deaf or hard of hearing and who has a physical disability.
Are you in need of, or could you benefit from the kind of assistance a Special Skills Dog could provide?
☐ Yes ☐ No If yes, please explain: ___________________________________________________________
What is your primary disability?
At what age were you disabled? _____ What caused this disability?
Is this disability progressive? ☐ Yes ☐ No If yes, please explain:
Do you have any secondary disabilities? ☐ Yes ☐ No If yes, please explain:
Do you have personal care attendants (PCA)? ☐ Yes ☐ No
If yes, how many hours each week do they work for you? How many times each day?
Do any PCAs live with you? ☐ Yes ☐ No
Will having an Assistance Dog reduce your need for PCAs? ☐ Yes ☐ No
What kind of assistive equipment do you use?
What forms of transportation do you use?
Describe your lifestyle in general (i.e. your social life, your home life, your hobbies):
Describe your level of activity (i.e. low, moderate, high, other):
Describe your level of energy (i.e. low, moderate, high, other):
Are you applying for a Diabetic Assist Dog?
☐
Yes
☐
No Do you have:
☐
Type 1/Brittle Diabetes
☐
Type II Diabetes *
*Note: We do not train dogs to assist an individual with Type II Diabetes.
Page 2 of 2
What is your height? ________________ What is your weight? _____________lbs
Please describe any limitations you might have with any of the following:
Mobility:
Physical strength:
Endurance/reduced stamina:
Balance:
Coordination:
Reaction speed:
Vision:
Hearing:
Speech:
Sensitivity to heat/cold:
Sensitivity to pain:
Depression:
Chronic pain:
Memory loss:
Muscle spasms:
Seizures (Frequency):
Blood glucose below 70 (Frequency):
Other:
Is there anything else we should know, or are there any comments you would like to make?
How did you learn of Can Do Canines?
All information is kept confidential.
Please return the following items to Can Do Canines to begin the application process.
1. $50.00 application fee (check or money order)
2. Signature portion of “Is An Assistance Dogs Right For You?”
3. Part I General Information
4. Part II Assistance Dog Application Information
5. Medical Release and Reference Form
Can Do Canines
9440 Science Center Drive
New Hope, Minnesota 55428
phone: 763-331-3000 fax: 763-331-3009
info@can-do-canines.org
Can Do Canines
9440 Science Center Drive
New Hope, MN 55428
763
-331-3000 office ● 763-331-3009 fax
info@can
-do-canines.org
Can Do Canines – Assistance Dog Application
Medical Release and Reference Form
I, (print applicant’s name), give permission for the physicians and professionals listed
below to release my medical and confidential information in writing or by phone to Can Do Canines. I understand that the information
regarding my physical and mental condition and abilities will be limited to information relevant to helping Can Do Canines determine
if I can benefit from having an assistance dog. Can Do Canines will not review actual medical records, but will instead receive
information provided through questionnaires completed by my physician and references.
My application is for a (check one): ☐ Hearing Assist Dog ☐ Diabetes Assist Dog ☐ Mobility Assist Dog
☐ Autism Assist Dog ☐ Seizure Response Dog ☐ Special Skills Dog
Applicant or Parent/Guardian Signature Date Signed Applicant – Date of Birth
Please send this form back with your assistance dog application. We need this contact information to send our medical form to your
doctor and our reference letter to your professional and personal contacts. All information is kept confidential.
Family/Primary Physician
Professional Reference – examples include: specialist,
therapist, counselor, social worker, clergy, supervisor, teacher,
Name
Name
Clinic/Hospital
Organization
Mailing
Address
Mailing
Address
City, State, Zip
City, State,
Zip
Phone
Phone
Fax or Email
Fax or Email
Relationship
Personal Reference #1 – examples include: friend, teacher,
coworker, not a family member/ significant other
Personal Reference #2 – examples include: friend, teacher,
coworker, but not a family member or significant other
Name
Name
Mailing
Address
Mailing
Address
City, State, Zip
City, State,
Zip
Phone
Phone
Email
Email
Relationship
Relationship
