Autism Service DogApplication Application Steps 1. Please review all of the information on our Applicant FAQs page. 2. Be sure to complete this questionnaire to make sure you meet the criteria for applying. 3. Consider whether your family meets all the criteria and if you are able to commit to our extensive training process. 4. If you still feel an autism service dog is right for you, we welcome you to complete our service dog application. *Please note, you must submit saved applications within 30 days or the draft will expire. Please download and complete the medical form to submit on page 5 Download Service Dog Application "*" indicates required fields Step 1 of 9 11% Part 1: Background Information on Applicant(To be completed by legal guardian) Name of Applicant* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant’s date of birth* Month Day Year Which ethnicity best describes your child?*Select all that apply. Asian American Indian or Alaskan Native Black or African American Hispanic, Latinx, or Spanish origin Middle Eastern or North African Native Hawaiian or other Pacific Islander Some other race, ethnicity, or origin White Prefer not to answer What is the applicant’s diagnosis?*APPLICANT HISTORY: Please complete to the best of your ability. Any questions regarding answers to the following will be addressed in the home interview.Please describe the following in regards to the applicant: Mobility*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Physical strength*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Reaction time* Fast Average Slow Balance*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Vision*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Speech* Verbal Non verbal Method of communication*Hearing*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Sound sensitivity*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Light sensitivity*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Touch sensitivity*Please use a number 1 - 10 (1 is low / least and 10 is high / most)Describe the applicant’s activity level* Low Moderate High How does the applicant deal with anger or frustration?*Is the applicant taking any prescribed medications?*Please listWhat is a typical day like for the applicant?*SCHOOL INFORMATIONIn what type of classroom does the applicant spend the majority of their school day?* Mainstream Integrated / ICT / Inclusion Specialized program Home Name of school applicant attends*Address of school* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If your child attends public school, what school district is this school located in?*Is the school aware of this application?*Does the applicant have a 1:1 aide while at school?* Part 2: Family and Lifestyle InformationLegal Guardian 1 Name* First Last Guardian 1 Email Address*Guardian 1 Cell Phone*Guardian 1 Alternate PhoneAddress is the same as the applicants* Yes No Address Guardian 1* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian 1 place of employmentPlease state the place(s) of employment if applicableGuardian 1 type of employment (job/profession)Guardian 2 (Mom/Dad/Step-Parent/Legal Guardian)*Would you like to skip this section? Please choose "yes" if there is no second guardian. No Yes Legal Guardian 2 Name* First Last Guardian 2 Email Address*Guardian 2 Cell Phone*Guardian 2 Alternate PhoneAddress Guardian 2* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian 2 place of employmentPlease state the place(s) of employment if applicableGuardian 2 type of employment (job/profession)Is anyone in the home a veteran or actively serving in the military?* Yes No If yes, please list branch, rank and dates of service.Applicant’s current living arrangements**The child must live at home with a legal guardian at time of placement. Number of children in family*Name(s) and DOB for eachDo you own or rent your home?* Own Rent Please describe your home*Method of transportation commonly used by applicant/ family* Own vehicle Public transportation Other A fenced-in yard is very good for exercising a young service dog; however, a dog also needs daily walks on leash. Are the dog’s primary handler(s) (parents) physically able to handle the strength of a young, active 65-85 pound dog?*Are the dog’s primary handler(s) (parents) physically able to walk two miles on a daily basis?*Are there any physical challenges with the primary handler(s) (parents) of which BluePath should be aware?*This is important for dog matching purposes. Examples: parent(s) with back injury, upcoming surgery, orthopedic injuries or ailments, etc. Describe your lifestyle*List activities and outings applicant and family enjoy, including weekends, summer camps, traveling, etc. Part 3: Dog InformationDoes the applicant or any member of the family have allergies to animals?* Yes No If yes, do you have a plan to address this?Is there anyone in your family that does not like dogs?* Yes No Does anyone in this house have a fear of dogs?* Yes No Is there already a dog in the family?* Yes No If yes, how many?Please describe (Breed and DOB)Are there any other pets in the home?* Yes No If yes, how many?Please describe (e.g., cats, other and DOB)The Applicant and DogsMy child is anxious or fearful when he/she sees a dog outside.* Never Rarely Sometimes Often Almost Always Explain (if applicable)My child is anxious or fearful when he/she hears a dog bark.* Never Rarely Sometimes Often Almost Always Explain (if applicable)My child has had fearful experiences with dogs.* Never Rarely Sometimes Often Almost Always Explain (if applicable)My child has had positive experiences and interactions with dogs such as: laughter, excitement and shared enjoyment.* Never Rarely Sometimes Often Almost Always Explain (if applicable)My child interacts with dogs.* Never Rarely Sometimes Often Almost Always Please elaborate and give some examples of typical interactions with dogs*Additional Dog and Family InfoDo you have a completely fenced-in yard?* Yes No If not, please explain how you will contain the dogDo you consider yourself knowledgeable in dog care and behavior?* Yes No Is the entire family committed to the idea of having a service dog?* Yes No Are you prepared to deal with the time involved in maintaining a service dog?*socializing, on-going training, exercising, grooming, toileting, etc. Yes No Are you able to financially commit to maintaining a service dog, which can cost over $1000 / year for veterinary care and food expenses?*This does not include unforeseen circumstances. Yes No What type of equipment (if any) is used routinely by the applicant to which a service dog would need to acclimate?*e.g., mobility aides, communication devices, stress and anxiety reducing items.BluePath's service dogs work with children who are able to walk in public places outside of the home without the need of a cart or stroller. Can your child walk outside of the home without the need of a cart or stroller?* Yes Sometimes No If you replied "sometimes" or "no" to the question above, please explain below.A BluePath service dog provides safety for a child out in public by adhering to the cues from the parent or guardian. The service dog cannot interpret a situation in the home as being safe or unsafe. With this in mind, describe the ways you believe a BluePath Service Dog can assist the applicant in his/her activities of daily living*A BluePath Service Dog attracts a great deal of attention out in public. Are you comfortable being in the public eye? How will you deal with the attention your child and dog receive?*Consent* BluePath is committed to the health and well-being of our service dog teams throughout their working lives. I understand that I will be required to meet with a BluePath trainer at least once annually.Do you have any other information or concerns that might assist BluePath Service Dogs in processing this application? Please list below:*How long have you considered getting a service dog?*How did you hear about BluePath?*Select all that apply. Word of mouth BluePath Family / Volunteer Service Provider (ex. Doctor, Therapist) Activity (ex. swimming, karate) Community Event (ex. autism resource fair) Internet Search Media (ex. television, news article) Social media Please provide the name of the specific person or event that led you to BluePath. You can write N/A if you found us via an internet search.*Who did you hear from? Where did you hear about us? Can you share the doctor/therapist that recommended you to us? What event did you attend? Gold stars will be given for very specific information. =)Why do you feel you are ready now?* Part 4: Recent Evaluation/Social History RequestPlease send an evaluation of your child, performed within the past two to three years, which includes a comprehensive social history. Evaluations may have been performed by psychologists, neurologists, teachers, behavior analysts, or other relevant professionals.* Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Part 5: Medical History Form(To be completed by physician)Please submit medical history form here* Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Part 6: Personal Reference LetterPersonal Reference Letter from a friend or family member from outside of the home stating how he/she thinks you would benefit from a service dog and the type of care you would provide. (Allowed file extensions: jpg, png, pdf)File*Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Part 7: Photographs of Applicant & FamilyPhotographs of the applicant and the immediate family.File*Accepted file types: jpg, png, pdf, Max. file size: 50 MB. Part 8: Graduate Fundraising and AmbassadorshipBluePath provides service dogs free of charge to ensure that finances are never a barrier for a family that needs help. It costs upwards of $40,000 to raise, train and match each of our dogs with their families. BluePath receives no government funding and relies on the generosity of the public to fulfill its mission. As a BluePath graduate, it is expected that you will help us raise funds so that we can continue to support our community - keeping children safe and providing joy and love. We would also ask that you act as an ambassador of our mission, through sharing stories and photos and speaking at fundraising and cultivation events. Thank you for your support.Consent* I acknowledge I have read the above note and understand that fundraising support and ambassadorship are an essential component of becoming a BluePath graduate.Consent* I understand that I will need to return to Dutchess County NY, at least once annually, to recertify my dog for public access. Public access testing can be scheduled Monday through Friday between the hours of 8:30am and 4:00pm.Parent / Guardian Signature* Part 9: Background Check ConsentAll household adults (18 and older) must consent to a background check. Please ensure everyone in your home is available to review and sign the consent forms for this part of the application.Background Check Consent*I hereby authorize BluePath Service Dogs, Inc. and its designated agents and third party company representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for the purposes of a business and/or client relationship, including, but not limited to, employment, volunteer opportunities, or client/dog recipients. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to, the following areas: criminal national database search (sex offenses, terrorist watchlist, FDA, GSA, OFAC, OIG); social security number; federal criminal national database; driving record; alias for all. I further authorize any individual, company, firm, corporation, organization, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to BluePath Service Dogs, Inc, contracted third party agency, and any/all agents or representatives. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, organization, or public agency may have, to include information or data received from all sources. I understand that I have the right to deny consent to the review of my background, and agree that BluePath Service Dogs, Inc. reserves the right to deny my application or terminate a partnership based solely on those grounds. I further agree, should I authorize BluePath Service Dogs, Inc. to review my background, the information provided from the data pertaining to me will be carefully reviewed, allowing BluePath Service Dogs, Inc. to take action of an appropriate nature, as they see fit, based on the findings from the consumer report, or investigative consumer report. I understand that while BluePath Service Dogs, Inc. does not automatically terminate or disqualify business relationships, including employment, volunteering, or client /recipient, for past criminal activity, certain offenses may eliminate me from such partnership especially if the offense is related to the responsibilities of the role (e.g., violent crimes, sexual offenses, recent major driving violations). I further understand that factors, such as, the nature of the offense and its relation to the role, the time that has passed since the offense and evidence of rehabilitation will be considered. I further authorize BluePath Service Dogs, Inc. to decide the appropriate course of action should a consumer report or investigative consumer report come back with unfavorable information. I understand that appropriate action could include, but is not limited to, termination of any/all relationships with the organization and its representatives, a new/different role within the organization, revoking driving privileges from organization vehicles or its professional property (including, but not limited to, service dogs and organization owned equipment), or an ineligibility for some or all future opportunities to partner with the organization, its affiliates, representatives, or individuals with a past partnership to the organization. According to the fair credit reporting act (FCRA), I am entitled to know if the considerations for which I am applying are denied because of information obtained from a consumer-reporting agency. If so, I will be notified and be given the name of the agency providing the report. I will also be provided with the report itself; any actions taken because of the report, in writing; and a copy of the FCRA summary of rights for my review. I will be given an opportunity to formally, in writing, dispute any actions taken against me within 7 business days of notice for BluePath Service Dogs, Inc. review and reconsideration, with an understanding that there is no guarantee the organization will choose a new appropriate action. By signing this document, I am providing BluePath Service Dogs, Inc. consent for an initial background check as well as any subsequent background checks deemed necessary, which can occur randomly and without warning, regardless of my current status (e.g. active or inactive) with the organization. I provide consent for a background checkPrimary Caregiver or Handler* First Middle Last Signature*Date* MM slash DD slash YYYY Email* Phone*Relationship to Application*Additional Adult First Middle Last SignatureDate MM slash DD slash YYYY Email PhoneRelationship to ApplicantAdditional Adult First Middle Last SignatureDate MM slash DD slash YYYY Email PhoneRelationship to Applicant Additional Adult First Middle Last SignatureDate MM slash DD slash YYYY Email PhoneRelationship to ApplicantAdditional Adult First Middle Last SignatureDate MM slash DD slash YYYY Email PhoneRelationship to ApplicantAdditional Adult First Middle Last SignatureDate MM slash DD slash YYYY Email PhoneRelationship to ApplicantCAPTCHA
