Solutions for People Created with Animals - Service Dog Training Pre-Application

The SPCA, 51 Carmelkat Ln, Flippin, AR 72634

Solutions for People Created with Animals

Bridging the Gap between Animal Shelters and Human Services

Making A Difference
Emergency Pet Services Program
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Disaster can strike anywhere, in many forms, and always without notice. Our Emergency Pets Services provides for you during times of personal crisis. Your Donation to the EPS program can make sure that when disaster strikes, we are prepared to assist in any area we are needed. Our Award Winning Disaster Resposnse Team offers assistance to pet owners as well as other organizations all across the state of Arkansas within 8 hours. We've been there for single families and entire communities.
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Service Dog Pre-Application Form

Please complete all fields.
Be honest, the answers you give here will not affect our decision to enroll you in our program.
NOTE: This is a pre-application only meant to give us a basic idea of your situation and of how we can best help you when we call.
There will be personal interviews and still more paperwork to complete before getting you enrolled in our program.
We will contact you at the information you provide below within a few days.

Your Name:

Your E-Mail:

Daytime Phone:
Best time to call:
AM PM Anytime

Are you legally disabled?
Yes No

Do you have a doctor's statement saying you would benefit from a Service Dog?
Yes No

Please give us an idea of your disablities:

Have you had a Service Dog before?
Yes No
If yes, please what breed & what happened to this dog?

Is there a reasonable expectation that your medical situation will allow you to use and benefit from your dog's skills for 8 to 10 years.
Yes No
If no, please explain:

Do you live alone?
Yes No
If no, (please list who else lives with you and how they assist you)

Do any other members of your household have a physical or mental disability?
Yes No
If so, how are they disabled and what are their limitations?

Do any other members of your household have a Service Dog in the home?
Yes No

Are there any other pets in the home?
Yes No

Is anyone in the home allergic to dogs?
Yes No

What type(s) of special equipment do you use:
A wheelchair
Electric Chair (i.e. hoveround or some other motorized chair)
A walker
Crutches
I am an Amputee

other:

None

Are you able to drive yourself?
Yes No No, but I have someone who drives me

Do you require the use of an aide?
Yes No

What do you need/want a Service Dog to do for you?

How can you pay for your dog? Click here if you are not yet aware of our prices.

Are you able to pay for a Service Dog yourself?
Yes No
If you are unable to pay for your dog, we may be able to help you with fundraising. This works as you set up appointments to speak at various group and organziational meetings, set up fundraisers at local stores, etc. If you answered no above, CLICK HERE FIRST, then check all that you can do to assist in paying for your dog.
My family will help me
I can set up fundraisers through my church
I can set up fundraisers through my VFW, Lions Clun, Rotary Club, Elks Lodge, or other group(s)

List which group(s) and/or organization(s) and their specific areas: (i.e. Rotary Club, Yellville, Lions Club, Harrison,)

I can set up fundraisers at public stores in my area
VA
I can follow a payment plan (will require a minimum $300 down payment)

or Other (please list)

Are there any questions you may have of us?

Thank you! We will contact you soon to discuss your situation in more detail!

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The North Arkansas Central SPCA is a non-profit organization chartered in April of 2004
by the Arkansas Secretary of State for the prevention of animal cruelty purposes
and approved as tax-exempt under section 501(c)(3) of the Internal Revenue Code.
Gifts to the Organization are 100% tax-deductible.

A North Arkansas / Southern Missouri assistance project.

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