Alert Dogs for Diabetic, and Extremely Allergic Kids

Foothills Kiwanis Club,

Boulder, CO

Alert Service Dogs for Kids

Excuse the format, but this page is under constructiom Please copy/paste it to word. Then  print it and mail per instructions at the end. 


Foothills Kiwanis Club of Boulder, CO

Alert Service Dogs (ASD) for Kids Academy

Academy Application Form

 

To become a candidate for enrollment in the ASD Academy that teaches families to train an Alert or Medical Response Dog for their afflicted child.  Preferred recipient ages range from 8 to 14 years.


 

Foothills Kiwanis Club of Boulder, Colo. considers the information submitted in this application to be confidential and it

Will be disclosed only to the Service Dogs for Kids selection committee and to the Club officers and Board of Directors.

 

1. Submittal Date ________________________

 

2._________________________________            _________Yrs     ________________       M__   F__       

Child’s Name                                                               Age                             Date of Birth                         Gender


 

3.  Child’s Disability         ___ Diabetes     ___ Allergy (to what ___________________)

 








Please describe child’s condition including severity and ability to control with medication or other means.  Attach additional supporting information, if necessary.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Are there any other conditions of the child which would adversely affect the child’s ability to provide basic care for a dog (feeding, exercising, grooming, etc.)?    ___Yes        ____ No

If yes, describe how these needs would be met. 

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

3. Name all adult parents/guardians residing with child:

 

     ____________________________      ____________________               ___________________

                Name                                                                                      Employer                                                   Position

 

    ____________________________       ____________________               ___________________

                Name                                                                                      Employer                                                   Position

4. Name(s) of parent/guardian who would become a member of the Foothills Kiwanis Club of Boulder, and regularly attend 1 hour training classes, twice per month in Boulder, Colo.

_________________________________________     ____________________________

 

5.  Name all children or other residents of household

 

   ____________________________        ______________________         ____________

                Name                                                      Relationship                                            Age

   __________________________            ______________________         ____________

                Name                                                      Relationship                                            Age

   ____________________________        ______________________         ____________

                Name                                                      Relationship                                            Age

   ____________________________        ______________________         ____________

                Name                                                      Relationship                                            Age

 

 

6. Type & breed of pets residing at household.       Ages of pets                   If dogs, formal obedience trained? (Y,N)

Type (Dog, Cat, etc)                            Breed                                     Age                        

 

__________________            _____________________      ___________                          _________

 

__________________            _____________________      ___________                          _________

 

__________________            _____________________      ___________                          _________

 

__________________            _____________________      ___________                          _________

 

Household dogs will be carefully evaluated during a home interview. The evaluation committee may judge that the presence of your dog(s) could interfere with effective puppy/child bonding, in which case, arrangements must be made for the subject dog to be absent for up to 4 months. Please describe how you would accomplish this temporary absence.

 

__________________________________________________________________________________________________

 

__________________________________________________________________________________________________

 

 

7. Residence:

                ____  Single Family home              ___ Own              ___ Rent

               

                ____  Condo/Town home             ___ Own              ___ Rent

 

               

                ___  Other  Please describe _____________________________________________

 

 

8. Will the home and work environment be such that the puppy will never be left home alone for more than 4 consecutive hours or more than a total of 20 hours per week?    ___Yes        ____ No

If Yes, and if both parents/guardians work full time, please describe how this will be implemented

______________________________________________________________________________

______________________________________________________________________________

 

9. How will dog be exercised and where will it relieve itself?

 

                ____Fenced Yard

___ _Other    -     Please Describe__________________________________________________

                10.  Dog ownership experience of parent/guardian attending Academy training classes.

 

                ____ Currently own a dog

                ____  Have owned and cared for  ____ dogs in the past

                ____  Have attended obedience classes with a dog

 

11.  By submitting this application, the undersigned agrees that Foothills Kiwanis Club of Boulder may contact the following individuals. Further, the undersigned agrees to process information release forms, as necessary, to allow us to discuss this case with the following individuals:

 

______________________________     ___________________________      ____________

School nurse name                                                 School name                                                           Phone

 

______________________________    ____________________________    ____________

Child’s Physician name                                           Physician’s Facility                                                  Phone

 

____________________________________________________________      ____________

Other individual(s) familiar with the child’s condition (optional)                                                          Phone

 

 

12.  If the selection committee wishes, will you allow committee members to visit your home and to interview the child, all parents/guardians, and other individuals residing at your home?

_____ Yes   _____ No

 

 

13. Do you live within 30 miles of Boulder, CO and/or are willing to attend twice monthly classes in the Boulder, CO area and to visit the Project Trainer in Boulder when direct consultations are required?

______Yes  _____No

 

 

14. If selected to enroll in our Academy, one adult member of the Family must join the Foothills Kiwanis Club of Boulder. There are two membership levels available. The Regular membership dues are about $50.00 per month, which gives the member full rights and privileges, and includes breakfast at all regular meetings and liability insurance covering the dog. There is also an Honorary membership with no dues, which entitles the member to attend any or all meetings, but the member will be charged $10.00 for the breakfast meal.  The liability insurance for the dog is included, but an Honorary member cannot vote or hold office. Please indicate your preference.

Regular membership    ______

Honorary membership ______

 

 

15. How did you learn about us?

____  ASD brochures

____ Foothills Kiwanis Club website

____ Project website—www.AlertDogs4Kids.org 

____ Member of ASD Academy

____ Media information

____ Other – Please Indicate ____________________________________________________

 

 

16. The principle contact regarding this application is:

 

_____________________________       ____________________________        ____________ 

Name (Please print)                                                                                Signature                                Date

____________________    ___________________     _________    ___________

Address                                                                   City                               State                  Zip

 

______________________      __________________________

Phone                                                      Email

 

 

Submit this application to:

 

Foothills Kiwanis Club of Boulder, CO

Attn:  Alan Boeve

4446 Pembroke Gardens

Boulder, CO 80301

303-530-4389 (h)

720-936-5720 (c)

 

Questions – please send email to alanboeve@aol.com or phone 720-936-5720