Diabetics Interested in Training?

Diabetic Alert Dog Training

If you are human, leave this field blank.

Client Name *

First

Guardian Name (if under 18)

First

Address *

Address

City

State/Province

Zip/Postal

Country

Email *

Home Phone

Cell Phone

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship to Emergency Contact:

1.) Please check the Diabetic type you have been diagnosed with:

2.) How long ago were you diagnosed?

3.) What is your current (average) insulin dosage per day?

4.) What has your A1C level been at your last few check-ups?

5.) Are you learning how to count carbs and control your diet?

6.) Are you currently on an insulin pump? 6.) Are you currently on an insulin pump?

7.) Are you currently experiencing any kind of liver or kidney failure or other physical issues that we should be aware of, and that could affect training? (If so, please explain below)

8.) Does your endocrinologist know that you are seeking a Diabetic Alert dog?

9.) Do they agree with your choice? Yes or No

10.) Do you currently have a dog that you believe would be suitable for DAD training? Yes or No

11.) If yes, please list the breed, age, gender, and personality characteristics of your current dog. If no, please skip this question and go to question 12:

12.) If you don’t currently have a dog you want to use for DAD training, are you willing to allow Off Leash K9 Training to help you select a dog for training? Yes or No

13.) Are you comfortable with a large dog, small dog, long haired dog, short haired dog? Please list preferred characteristics or breeds:

14.) How active are you? 14.) How active are you?

Captcha

Check to agree *

I Agree

**I acknowledge that all information provided is given voluntarily by the adult submitting this application for admission to Off Leash K9 Training’s Diabetic Alert Dog Training Program. The adult client or guardian answering these questions and clicking "agree" on this form does state that they are of clear mental health to apply to this program, and understand that the answers to the below questions are only to be used by Off Leash K9 Trainers to better customize your training experience and determine your eligibility for their Diabetic Alert Dog Training Program. Submitting this application does not guarantee acceptance to said program. **

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