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Application

Thank you for completing the application from the National Institute for Diabetic Alert Dogs Inc. The addition of a service dog into a person’s life is a big commitment. The benefits, both physical and emotional, are significant. Once your application has been reviewed, an initial interview will be scheduled to discuss the specifics of our program, and how a dog may fit into and benefit your life.

Following approval of your application a purchase contract will be provided for your service dog.

The National Institute for Diabetic Alert Dogs Inc. respects the privacy of its applicants and all information is kept confidential. We may share non-personally identifiable information with service dog industry accreditation agencies for the purpose of maintaining the highest standards of excellence within the service dog industry.

The National Institute for Diabetic Alert Dogs Inc. conducts its business and acceptance process in a manner that does not discriminate against anyone on the basis of race, color, religion, gender, national origin, age, the presence of mental or physical disability, sexual preference, or life expectancy. Nidad’s policy is to treat everyone who comes in contact with the organization with respect and dignity at all times.

Name Birthdate

Parent or guardian if minor

Home Phone Cell Phone

Emergency Contact Phone

Email

Address

City

State/Zip

Please tell us how you heard about us? i.e. friend (who?), internet, BgConnect

Have you ever owned a dog before?
Yes
No

Have you ever owned a service dog before?
Yes
No

To maintain optimal health of a service dog proper care and nutrition is required.
Monthly costs, excluding veterinary care, typically are $80 to $100.
Are you willing to accept this financial obligation?
Yes
No

Preventative veterinary and health care (i.e. heart worm preventative,
flea and tick preventative, dental care, vaccinations, health exams, grooming ),
excluding illness, injuries and emergency veterinary care, typically costs $500 annually.
Are you willing to accept this financial obligation?
Yes
No

Other than your service dog are you planning on obtaining any other animals within the next year?
Yes
No

Please explain your reason(s) for wanting a Diabetic Alert Service Dog

Please tell us the type of home you have i.e. apartment, single/multi level, high rise

Please list names and ages of adults and children that live in the home

Do you have stairs?
Yes
No

Do you have an elevator?
Yes
No

Do you have yard?
Yes
No

If you have a yard is it fenced and secure?
Yes
No

Please describe the area that will be utilized for your dogs relief area (restroom)

Do you have a motor vehicle?
Yes
No

If you have a motor vehicle please provide make, model and year

Please describe public transportation that you use and how often, i.e. bus, subway, airline

Are you a student?
Yes
No

If yes please provide grade level, school address, principals name

Are you employed?
Yes
No

If yes please describe occupation and work environment i.e. office, factory, busy, noisy

Describe your lifestyle and activity level i.e. hobbies, sports, etc.

At what age were you diagnosed as a Diabetic?

What was the date of your last A1c?

What was the result of your last A1c?

Type of diabetes?
Type 1 Type 2

Insulin dependent?
Yes No

Insulin delivery method?
Pump Injection

Do you have any of the following conditions?
Deafness / Hearing loss
Speech impairment
Vision impairment
Limited mobility
Muscular weakness
Memory loss
Allergies
Chronic pain
Heightened emotions
Depression
Attention deficit disorder
Hyper activity disorder
Skin sensitivity
Heat / cold sensitivity
Balance or coordination problems
Kidney disease
Kidney dialysis
Neuropathy
Retinopathy
Amputations
Other condition - Please specify

Do you use any of the following?
Glasses
Prosthesis
Leg brace
Wrist brace
Cane or crutch
Walker
Manual wheelchair
Electric wheelchair
Hearing aid

Are you or anyone in the household allergic to dogs?
Yes
No

If yes please describe who is alergic to dogs

Do you use tobacco products?
Yes
No

Does anyone in the household use tobacco products?
Yes
No

Please describe any dogs that live in the household or visit often. Include breed and age.

Please describe any other animals that live in the household or visit often

Please provide any additional information you feel is relevant