Owner coaching ESA application form

How did you hear about us? * Website\|Petrescue\|Facebook\|Instagram\|Radio\|WordofMouth\|Other
Owner First Name *
Owner Surname *
Street Address *
City *
State *
Post Code *
Phone Number *
Email Address (non NT Gov or NT Schools email addresses please)(Please check spam folder as you will get an automatic email once you submit this form and future emails may also go there) *
Facebook Profile
Animal Name *
If you have a puppy whom you plan to train for an ESA you will be required to attend puppy classes with PAWS Darwin *
Gender *
Breed *
Size *
Date of Birth *
Colour *
Is your dog Desexed *
Is your dog up to date on vaccinations *
Does your dog have any known health issues which could impact training? *
If yes above please supply details?
Does your dog have any known behavioural issues we need to know about? Especially reactive behaviour? *
If yes above please supply details?
What specific requirements do you want to train your dog for? *
SERVICES PROVIDED: Classes are taught by Lisa Hansen, a professional dog trainer, and her team.
I understand that there will be a fee payable for the coaching. This fee will be $20 per week wether you attend sessions or not. *
The Trainer, at his/her discretion, may refuse entry to any dog which is not healthy, is aggressive or does not seem suitable for the services provided. *
I understand that there will be a fee payable for the assessment. *
REMOVAL FROM TRAINING: Trainer, at his/her sole discretion, may remove a pet from class if a hazard or threat of any nature to any other animal or person is present. No refund will be given under such circumstances. *
I/ or someone in my family has the following disability/support requirements. *
CLEANLINESS: Owner is responsible for the removal of excrement that their pet is responsible for *
LIABILITY: Owner agrees to indemnify and hold PAWS Darwin Trainer and Trainer’s employees/agents harmless from all liability for any loss, damage or injury to persons, animals or property arising from or related to Owner’s pet. *
Owner agrees that Trainer shall not be liable for loss or damage to animal for any reason unless said loss or damage was a direct result of Trainer’s negligence. *
I understand that it is up to me to compete all public access testing and to abide by NT regulations for support dogs. I understand that I need to ensure that i have the doctors certificates etc required to show that i am eligible for an emotional support dog. *
I understand that my dog and myself may be recorded during training, this recording is used to assist and encourage better training for dogs owners and trainers, and while every effort is taken to avoid faces and conversations the nature of the camera may overlap, i agree that i may be photographed and if i do not want to have footage used with myself in it then i will talk to the instructors and let them know. I understand all efforts to protect privacy will be taken. *
Signature of Applicant. Please use your finger on touch screen or click and hold your left button to use your mouse above the line. * Please sign on screen or click and hold your left button to use your mouse.
Date *