Our Service Dogs at
Universal Studios in Florida

Mountain High Dog Training
Life Enhancing Canines
Breed responsibly, Train properly, & Change lives globally.

Service Dog Application

Thank you for the opportunity to service your service dog needs.

Tigger Lilly
She is now working as a seizure response service dog in Oregon

Applicant Contact Information

Please tell us about yourself.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Tell us more:	Enter comments here!

Beszedes Katalynn, trained to secent for peanuts and is shown here blocking peanut products at a local Walmart.

Potential Service Dog Recipient
Background Information / Application

We would like to get more information regarding the medical condition and the lifestyle of the Potential Service Dog Recipient (PSDR).

Name of a Contact Person:
*What is your physical address?:*
Phone number where you can be reached:
Email address:
What type of Service Dog needed:	Epilepsy / Seizure Assistance Allergy Alert / Assistance PTSD Stability Diabetic Alert / Assistance Other
Name of person in need of service dog:
Age of person in need of service dog:
Primary caretaker if PSDR in under 18 yrs of age:
*Is there anyone that smokes in the home?:*	Yes No
Are there any additional animals in the home?:
If Yes: how many and what type of animals are in the home:
What is your primary mode of transportation?:	Own Car Private Transportation Public Transportation Other
Tell us about your &/or your family's lifestyle:	Highly Active Active Balanced (both active and relaxed) Relaxed (do some activities not on a regular basis) No Activity (no regular activities)
How long has PSDR been diagnosed?:
If the PSDR has allergies, What type are they? :
If PSDR has Epilepsy/Seizures: What type and how frequent are they?:
If the PSDR needs a Stability SD: What caused the instability:
If the PSDR has PTSD please describe the symptoms. :
If the PSDR has diabetes: What type :
Does the PSDR use any medical devices to aid in physical mobility:
What other medical issues, if any, does the PSDR have:
Is the PSDR physically capable to handle a SD:	Yes No
Is the PSDR able to exercise the SD on a daily basis:	Yes No
If the PSDR has answered no to being able to handle a SD or to exercising SD: explain why:
Are there any household members, that may have health issues with the SD being indoors?:	Yes No
If yes to health issues: then explain:
A service dog is not a pet. A SD goes everywhere with the PSDR. Are you prepared to take the dog with you everywhere.:
What is your definition of a SD?:
What breed of dog are you comfortable having as a SD? This is taken into consideration when evaluation the recipient's application.:
ADA Law requires SDs to perform tasks that your are not able to perform for yourself. What tasks are you wanting your SD to perform?:
Are you able to provide basic vet care for your SD, and basic necessities? If you are not able to, please explain in detail why you are not able to provide basic care for the dog:
Once the dog is completely trained and is a Certified SD the training does not end. Are you prepared to continue the training of the dog for the duration of its working life? If no explain why:
Now is your time to tell us anything else that you feel is important for us to know about you, your home, or your lifestyle:

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Service Dog Application

Thank you for the opportunity to service your service dog needs.