AUTISM SERVICE DOGS OF AMERICA APPLICATION

1. Run away from caregivers?___never ___sometimes___frequently

2. Demonstrate hyperactive behaviors?___never___sometimes___frequently

3. Demonstrate impulsivity?___never___sometimes___frequently

4. Demonstrate aggressive behavior toward others? ___never___sometimes___frequently

5. Experience temper tantrums?___never___sometimes___frequently

6. Experience a very sort attention span?___never___sometimes___frequently

7. Experience oversensitivity to sound?___never___sometimes___frequently

8. Experience oversensitivity to being touched?___never ___frequently

10. Demonstrate extreme or abnormal moods?___never___sometimes___frequently
      (giggling or weeping for no apparent reason)___never___sometimes___frequently

11. Demonstrate a lack of fear to real dangers (age appropriate)
      ___never ___sometimes___ frequently

12. Demonstrate self-injurious behavior?___never___sometimes___frequently

13. Experience difficulty in forming peer relationships?___never___sometimes___frequently

15. Delay in development of spoken language?___yes___no

16. Lack the ability for creative, imaginative play?___yes___no

17. Lack the ability to initiate or sustain conversation (age appropriate)?___yes___no

19. Demonstrate repetitive use of language or idiosyncratic language?___yes__no

20. Fail to share enjoyment, interests or achievements with others?___yes___no

21. Demonstrate a lack of social or emotional reciprocity?___yes___no

22. Demonstrate frustration/irritability with minimal changes in routine
       ___no ___Mild___Moderate ___Severe

24. My child is a ___boy___girl and is___years of age.

Print, read, sign, and mail with other documents the following agreement:

  I understand and accept the responsibility, financial investment, and care required of owning a (service) dog. All family members will respect the basic needs of the dog for proper diet, shelter, veterinary care, exercise, attention, and rest. If, at any time, I, or members of my immediate family, cannot meet the requirements of proper care, I understand the service dog is to be returned to Autism Service Dogs of America. I further agree to maintain the ASDA training standards of our service dog

Signed_________________________________________Date_____________
______________________________________________Date_____________
Secondary caregiver Signature
                 

Full name of primary child caregiver/ dog handler

Primary caregiver name:______________________________________________
Primary caregiver address:____________________________________________
City__________________________________State________Zip Code________
Phone:____________________________Email:___________________________
Child’s Name______________________________DOB:____________________

ASDA
4248 Galewood St.
Lake Oswego, OR 97035