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 Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe 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: Type 1 Type 2 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? Yes No Other 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? Not Active at all Somewhat Active Pretty Actice Extremely Active Other 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. **
