BLUE RIDGE ASSISTANCE DOGS
Preliminary Application
Name: _____________________________________________________________________
Title: ________________________________________ Date: _____________________
Address: __________________________________________________ Apt # _________
City: ______________________________________ State: ____ Zip: _____________
Home Phone: _________________________ Work Phone: _________________________
E-mail: __________________________________________ County: ________________
How did you hear about us? ________________________________________________
Date
of Birth:
_______________
Male/Female: _______________
Approximate weight:
______________
Approximate height: _______
Occupation: ______________________________________________________________
What is your primary disability? _________________________________________
What caused your disability? _____________________________________________
Please list secondary disabilities, if any: ______________________________
___________________________________________________________________________
At what age were you disabled? ____________
Is your disability progressive? Yes / No
Further description of disability:
What kind of Assistance Dog are you looking for?
Guide
__________
Service ________ Hearing ________
Social/Therapy __________ Seizure ________
Other __________
Why do you want an Assistance Dog?
What needs or services will an Assistance Dog provide?
Additional Comments:
BLUE RIDGE ASSISTANCE DOGS
Application Process 1) The applicant contacts Blue Ridge Assistance Dogs (BRAD) by mail, phone, or e-mail.
2) BRAD contacts the applicant, providing information about the program and inquiring about the applicant.
3) If BRAD believes the applicant will benefit from an Assistance Dog, a Preliminary Application is submitted to BRAD.
4) The Preliminary Application is submitted to BRAD.
5) The applicant is contacted to arrange for a personal interview.
6)
The interview is usually held in the applicant's home with two
representatives of BRAD and one dog participating. If the applicant's
home is at a great distance, other arrangements may be made. The
Interview Form is completed during the interview and the $50
application fee is received.
7) Following the interview,
if it is still believed that the applicant would benefit from an
Assistance Dog, BRAD will send the applicant the Secondary
Application.
8) The applicant completes all parts of the
Secondary Application and gives the supplementary pages to appropriate
individuals for completion. All portions are sent to BRAD. At this
point, a payment schedule is discussed. BRAD will attempt to be
flexible in working with the recipient.
Each recipient is
responsible for not less than $7000 of the total cost of $14,000 that
it takes to train and place an Assistance Dog with a person with a
disability. BRAD will provide assistance in ways to raise money for the
fee. If BRAD or the client feels that he/she would qualify for
supplementary funds from outside sources, BRAD will give assistance in
making application for these funds.
9) When all parts of
the application forms have been received, BRAD will review them and
notify the applicant whether they are to receive a dog. BRAD provides
the best match possible for the recipient and the dog. The recipient
will be contacted when a suitable dog has been identified. All
paperwork must be completed and payment of fees agreed upon before
recipient/dog Team Training begins.
10) The applicant must
demonstrate the ability to pay for the daily expenses of caring for the
dog. These expenses include, but are not limited to, food, veterinarian
expenses, heartworm prevention, and replacement equipment.
Please mail to:
Blue Ridge Assistance Dogs
P.O. Box 229
Manassas, Virginia 20108
