ESA application form

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

prefered Breed or type of dog *

Are you using your own dog? If yes, please fill out dogs details below. *

Animal Name

Gender

Date of Birth

Is your dog comfortable with other dogs? *

Breed

Has your dog bitten anyone before for any reason? *

Is your dog de-sexed?

Is your dog up to date on vaccinations?

Is your dog microchipped

Do you have any illness or allergy that could be detrimental to having a support dog *

If yes above please supply details?

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 dog i am applying for. *

I/ or someone in my family has the following disability/support requirements. *

REMOVAL FROM program should a dog and handler be incompatible of if there are any acts of violence or aggression towards the dog or the trainers. No refund will be given under such circumstances. *

CLEANLINESS: Owner is responsible for the removal of excrement that their pet is responsible for *

The cost of belonging to the Heart Dogs Program is $25 per week, this cost must be direct debited to the nominated account and covers classes and communication support, if you do not attend classes this cost must still be paid. *

There is a cost of $100 for assessment of Dog and Handler partnership, this assessment must be carried out before you can be accepted into our program, it is a one off non refundable payment even if you do not pass assessment. Please note we are not assessing your need only your partnership. *

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 handlers 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. *

i agree that if my dog and i undergo assessment it will cost $100 on the day of assessment *

Date *

How did you hear about us? *

Signature of Applicant. Please use your finger on touch screen or click and hold your left button to use your mouse above the line. *