Name: (If a minor, Name is Child s Name on all our forms) Address: Type? Circle: Mobile Home Work Other. ( ) Name of Health Insurance Company:
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1 APPLICATION FOR TRAINING A SERVICE DOG Name: Address: (If a minor, Name is Child s Name on all our forms) Telephone: Type? Circle: Mobile Home Work Other Type? Circle: Mobile Home Work Other ( ) Health Insurance Information: Name of Health Insurance Company: Complete Address: Telephone Number(s): Member or ID Number: Name of Primary Insured if NOT Applicant: Relationship to Insured: Child, Spouse, Other: (please circle) explain Group Name: Treatment Authorization Number: If you have Medicare or Medicaid, please complete the health insurance information above. If you have Medicare and a supplemental policy, please provide the supplemental information on the back of this page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If you do not live in a metropolitan area, please tell us the major city closest to you with an airport and describe where it is in relation to your home. For example, Approximately 30 miles east of Tampa International Airport, just off I-4. 1
2 Date of Birth: Time of Birth: A.M. or P.M. Place of Birth (City, State, Country) Female or Male (please circle) Social Security Number: Name of Nearest Relative: Relationship: Phone Number(s): Address: Marital Status of Diabetic/Disabled Person: Single Married Divorced Type I (juvenile insulin dependent) diabetes mellitus ( ) Yes ( ) No Type I (insulin dependent adult) diabetes mellitus ( ) Yes ( ) No Type II (adult onset oral medication) diabetes mellitus ( ) Yes ( ) No Type II (insulin dependent adult) diabetes mellitus ( ) Yes ( ) No OTHER HEALTH CHALLENGES? Height Weight PLEASE CHECK ALL THAT APPLY. If the question does not apply, leave it BLANK!!! What are the effects of your disability? ( ) Failure to recognize hyperglycemia ( ) Failure to recognize hypoglycemia ( ) Deafness ( ) Speech Impairment ( ) Reduced Stamina ( ) Hearing Loss ( ) Coordination Problems ( ) Limited Mobility ( ) Memory Loss ( ) Spasticity ( ) Slowed Development ( ) Vision Impairment ( ) Muscular Weakness ( ) Other: Do you have any problems with. ( ) Brittle Diabetic (wide swings in glucose) ( ) Allergies ( ) Chronic Pain ( ) Heightened Emotions ( ) Depression ( ) Skin Sensitivity ( ) Balance ( ) Brittle Bones ( ) Heat/Cold Sensitivity 2
3 ( ) Seizures- if yes, what type and how often? Also, what treatments or medications are you using or have you used to control your seizures? Do you use any of the following aids or assisting devices? ( ) Prosthesis ( ) Leg Brace ( ) Electric Wheelchair ( ) Manual Wheelchair ( ) Wrist Brace ( ) Hearing Aid ( ) Crutch/Cane ( ) Walker ( ) Other: Are you active in the military, a veteran, or a dependent of an active member of the military or veteran? If yes, please explain. Primary Care Physician, PT, OT and/or Other Health Professionals Important to Your Care (Please list ALL with phone numbers. Separate Sheet is OK): Housing: Home Apartment Other (Describe): Yard With Fence Without Fence Please list all persons living with you: Name Relationship Age Do you have an attendant? ( ) Yes ( ) No Full-Time Part-Time Please describe your home and your neighborhood (i.e., quiet, lots of visiting children, close to retail/commercial, suburban, rural, lots of traffic, etc.): 3
4 Have you ever had a dog? Describe your experience with your dog: Have you ever had a Poodle? Describe your experience with your Poodle: Do other animals live with you or visit you frequently? If so, please describe (including breed, sex and age). Who is responsible for the care of these animals? Who will assist in the daily care and training of your dog, if appropriate? Does anyone in your household have concerns about having a diabetic or medical alert service dog in their home? If so, please explain: Are you (or anyone in your household) allergic to animals? Are you (or anyone in your household) concerned about fleas, shedding? Are you currently employed? If so, do you want your dog to assist you while at work? In what way? Have you discussed with your employer / co-workers having a service dog in the workplace? Are they supportive? Are you currently in high school? If so, do you want your dog to assist you while in school? In what way? 4
5 Have you discussed with your principal / teachers having a service dog in school? Are they supportive? Circle five of the following words that would describe the service dog you would like to have: serious slow playful slow calm willing attentive energetic sensible responsible smart protective dependable stable confident happy sweet easy going independent assertive devoted submissive friendly dependent loving trusting excitable communicative Circle five of the following words that would describe traits you would not like to have in a dog: serious indifferent distracted slow calm playful manipulative stubborn protective resistant jealous fearful excitable assertive submissive joking foolish dependent no-nonsense Describe your means of transportation: Are you available to attend training classes or counseling sessions at Sugar Dogs Headquarters? ( ) Yes ( ) No How do you feel a diabetic alert service dog could improve your life? With what specific tasks would you hope a dog could help you? Please tell us a little more about yourself hobbies, activities, clubs, interests, etc.: 5
6 Because it is important to teach others about service dog teams, what kind of community service would be of interest to you? What questions or concerns do you have that we may address? Please also send: A recent photo of the person If diabetic, A1c laboratory results for the past year (lab reports only please) Medical History Form signed by your physician Donation to Sugar Dogs International, Inc.* By signing this application, I promise to practice the Sugar Dogs International Training Method for myself and my Sugar Dog, OR on behalf of my minor child and his/her Sugar Dog, in good faith, with consistent practice. Also, I understand that the Training Method is protected by international copyright and trademark laws, which means I cannot share the Training Method with anyone and will monitor my minor child so that this secret is not inadvertently shared, and prohibit the infringement of the copyright and/or trademark secret. Applicant Signature: Date: If a minor, this form should be signed by parent Printed Name of Person Signing Application: Please return to this original document to: Sugar Dogs International, Inc. 804 W. Hamlin St. Plant City, FL
7 We have no fees; however, we will bill your insurance company for the full cost of the training. PLEASE make a donation. Friends, family and your local community can make donations on your behalf. Many donate on a monthly or quarterly basis. The average donation is $7, per Diabetic or Disabled Person. Donations are tax deductible up to $13, for the current tax year per taxpayer (2014). We anticipate that it will take two (2) years to become a reliable Sugar Dog team. Last Revision: 4/2/2014 7
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