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Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Home
About
Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Home
About
Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Home
About
Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Home
About
Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Home
About
Autism Service Dogs
Facility Programs
- Paws to Learn Program
- Facility Therapy Dogs
Get Involved
Contact

Autism Service Dog
Application

Please review all of the information on our Applicant FAQs page. Consider whether your family meets all the criteria and if you are able to commit to our extensive training process. 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

Service Dog Application

"*" indicates required fields

Step 1 of 8

12%

Part 1: Background Information on Applicant

(To be completed by legal guardian)

Name of Applicant*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Applicant’s date of birth*

Month

Day

Year

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 list

What is a typical day like for the applicant?*

SCHOOL INFORMATION

In 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 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 Information

Legal Guardian 1 Name*

First Last

Guardian 1 Email Address*

Guardian 1 Cell Phone*

Guardian 1 Alternate Phone

Address is the same as the applicants*

Yes

No

Address Guardian 1*

Street Address Address Line 2 City State ZIP Code

Guardian 1 place of employment

Please state the place(s) of employment if applicable

Guardian 1 type of employment (job/profession)

Guardian 2*

Please choose "no" if you would like to skip the following section.

Yes

No

Legal Guardian 2 Name*

First Last

Guardian 2 Email Address*

Guardian 2 Cell Phone*

Guardian 2 Alternate Phone

Address Guardian 2*

Street Address Address Line 2 City State ZIP Code

Guardian 2 place of employment

Please state the place(s) of employment if applicable

Guardian 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 each

Do 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 Information

Does 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 Dogs

My 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 Info

Do you have a completely fenced-in yard?*

Yes

No

If not, please explain how you will contain the dog

Do 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?*

Why do you feel you are ready now?*

Part 4: Recent Evaluation/Social History Request

Please 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

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

Accepted file types: pdf, jpg, png, Max. file size: 50 MB.

Part 6: Personal Reference Letter

Personal 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 & Family

Photographs of the applicant and the immediate family.

File*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Part 8: Graduate Fundraising and Ambassadorship

BluePath 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*

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BLUEPATH SERVICE DOGS, INC. IS A 501(C)(3) NONPROFIT, EIN # 81-3606565

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