Your Name *
Address Line 1 *
Address Line 2
City *
State *
Zip *
Email Address *
Phone Number *
Name of person in need of Allergy Alert dog
Primary Caretakers, if under 18
Age of person in need of dog*
Are there any household members whom dogs would harm their health? If yes, explain.
Would the Potential Dog Recipient (PDR) be available to travel to Colorado for a one to two week period of time to learn training methods and become acquainted with your Service Dog Yes No Maybe
What type of allergies does the PDR have
How frequent are the PDR's anaphylactic reactions
How long has the PDR been diagnosed with life-threatening allergic reactions (anaphylaxis)
What other means has the PDR taken to control your allergies? List medications, operations, or any other method
How did the PDR become aware of Allergy Alert dogs and their abilities
How would you describe the area in which the PDR lives Urban Suburban Rural Other
How would you describe PDR's current housing situation House Apartment Other
How would you describe the stability of the PDR's living arrangements Likely to change significantly in the foreseeable future Not likely to change significantly in the foreseeable future Unknown
How would you describe the PDR's lifestyle Highly Active Active Balanced Relaxed Highly Relaxed
Please state what methods of transportation are readily available to the PDR
Please list all people currently living with the PDR, as well as their relationship to the PDR and all allergies.
Please list all pets currently living at the PDR's place of residence
What do you want the Allergy Alert Service Dog to do for the PDR
Please list at least 3 traits you would like to see in the PDR's Service Dog
Please list at least 3 traits you would not like to see in the PDR's Service Dog
Does the PDR realize that an Allergy Alert dog requires continual training and upkeep? Yes No
Is there anything else that you feel that ASD needs to know about you
Coming Soon! - The first in a series of children's novels for grownups too. The Mighty Friends' Alliance: Volume One - "The Allergy Friends" by Sherry MersReserve Your Copy
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