First Responder Individual Service Dog Application

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Personal Information

First Name

Last Name

Birthdate

Street Address

City

State/Province

Zip/Postal Code

Country

Marital Status

Primary Phone

Alternate Phone

How did you hear of Puppies Behind Bars?

Employment Details

Current Status of Employment

Public Department Worked in

Years on the Job

Occupation/Job Title

Please describe your position with your place of employment in detail, including what capacity you worked in, and during which years.

Did you respond to the World Trade Center on September 11th or did you work at the site thereafter?

Yes
No

Please tell us how long you were assigned there (approximate dates are fine).

What were you like before your job?

What were you like when you retired? Did you retire willingly or were you forced to retire?

Dog Care

Do you have a fenced-in yard?

Yes

Please supply dimensions:

Is there a dog park near you?

Yes

Please provide the name and address link (if possible), as well as dimensions

Where will our dog get to run and play off-leash?

How would you exercise a dog? Our dogs are Labrador retrievers who need at least one hour of good, hard running off-leash each day. How can you provide that? If you cannot, then our dogs are not the right breed for your household.

Have you ever had an experience with a dog before?

Yes

What kind and when? What happened to that dog/dogs?

Your Needs

We specialize in training dogs for clients with PTSD. Our dogs are taught special commands such as "Got My Back" to help you in check-out lines at supermarkets; they are taught to awaken you from nightmares; and various commands to provide tactile grounding if you experience a panic attack or flashback. What, ideally, would you like a dog to do for you?

If your application is accepted, you will attend a fourteen-day training during which you will be paired and trained with a service dog specifically chosen for you. The home base for this training takes place at a conference center on four hundred-plus acres of wooded land which we traverse several times a day, up and down significant hills, in order to get from point A to point B. We also spend nearly two hours exercising the dogs on hiking trails on the property every day. This enables class members to enjoy daily recreation together and allows our service dogs to get a chance to run off-lead and play. Will hiking on this property or in a similar state park present too much difficulty for you?

YesNo

Is there a specific incident you or your doctor can link your PTSD or anxiety to, or is it cumulative? Please be as descriptive as you are comfortable being.

A prerequisite for getting a dog is a desire, on your part, to become more independent. How would you get across to us that you do, indeed, want to become more independent?

Please list at least two people who may care for your service dog the event of an emergency such as an unforeseen hospitalization or sickness. Please provide names and contact information for each and your relationship to them. At least one of these contacts should live outside your home.

Please upload a photo of yourself that has been taken within the last two weeks.

You may upload your image file with the following extensions: .jpg .jpeg, .png, .tiff, .gif, and .pdf. Please do not upload images embedded in document files, eg. Word, Powerpoint, etc.

Service Dogs for Those Who Serve And Protect Agreement

Puppies Behind Bars (PBB) pays the costs associated with training our dogs and matching them with first responders. PBB will pay for travel and lodging expenses for the first responders to travel to the fourteen-day training where the participant and dog are trained to work together. PBB will also provide most of the meals, but on the nights when we do not go out to dinner together as well as nights you choose to either eat in your hotel room or go out with other participants, those costs will be yours. If you drive to team training and wish to be reimbursed for gas and tolls, please save and remit all receipts. Thirty days after receiving your receipts, PBB will reimburse gas and toll expenses. PBB will not reimburse incidentals such as food or beverages consumed in transit or cultural or entertainment expenses incurred during the fourteen days of training with the dog, nor gasoline used during team training, if you drive.

If, at any time and for any reason, I find that it is impossible to keep the dog I have received from PBB, I will contact PBB and will return the dog to the organization. I will neither sell nor give the dog to anyone, including a family member. PBB will make all arrangements to pick up the dog and no questions will be asked. In addition, PBB feels that the dog's happiness and health are of prime importance, and will take back any dog whose quality of life is not of the highest standards, which includes that the dog maintains a healthy weight, receives proper veterinary care including monthly doses of Heartgard, Nextgard, and Frontline, one hour of off- leash outdoor exercise each day, and lives in the house and is not tied up outside or in a kennel. We will also take back the dog if you do not stay in touch with us, meaning that you do not return our calls, emails, texts, etc. Accordingly, I agree to abide by all of PBB’s follow up and recertification policies and procedures.

PBB will retain ownership of the dog for the life of the dog to ensure that you are working well with the dog and the above standards are met. While we have no intention, or desire, to take a dog back, past experience has shown us, unfortunately, that sometimes it is unavoidable. PBB reserves the right to remove the dog from its placement at any time if one or more of the following situations exist:

The recipient is unable to properly care for the dog, as determined by PBB, including but not limited to the dog maintaining his or her placement weight. The recipient becomes incarcerated, the recipient becomes hospitalized for an extensive period of time, or the recipient is moving outside of the United States. It is up to the recipient to notify PBB of any incarceration, long-term treatment, or international move.
The dog is being neglected or abused, or not exercised.
The dog is no longer being used as a service dog by the recipient.
The recipient uses the service dog in a manner that violates the standards for service dogs established by PBB and Assistance Dogs International (ADI).
The dog and handler do not pass the annual Public Access Test administered by PBB.

PBB will make site visits when I am home with my dog after approximately three months and will test me and my dog annually. I may have to travel to meet PBB instructors for my annual visits. I agree to do such travel and agree that I will comply with all these visits, as well all emails, texts and phone calls from PBB staff and instructors.

I also agree that PBB instructors may speak with my current health care provider and/or future health care providers throughout my dog’s life. I understand that sometimes problems can be resolved by PBB asking my health care provider to intervene

Accept the agreement:

I have read this agreement and unconditionally accept the terms and conditions set forth by Puppies Behind Bars.

Please acknowledge your consent"

I give my consent to Puppies Behind Bars staff to speak with my personal references, my health care provider, and my significant other as a part of this application process. I understand that any information my references share with PBB staff is confidential and that Puppies Behind Bars will not share those details with me or any third party.