Purposeful Placement Application Form "*" indicates required fields Purposeful Placement Dog Program Application Form Applicant Personal InformationName* First Last Preferred NamePronouns He/Him She/Her Other Date of birth* DD slash MM slash YYYY Primary LanguageCultural IdentityDo you personally know any ADA staff member* Yes No Contact Information* Street Address Address Line 2 City Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile*Home PhoneEmail* Emergency Contact* First Last Please complete this section in full and be as honest as possible. The detail you provide is essential to successfully match a Purposeful Placement Dog to you. Applicant Living CircumstancesType of Home House Unit Townhouse Acreage Group home Other Is there a yard? Yes No Is the yard fully fenced? Yes No Who does the applicant live with? Partner Housemates Alone Other Please provide details of all people living in the household (even temporarily)Name Add RemoveAge Add RemoveRelationship Add RemoveDisability/mental health/behavioural issues Add RemoveDoes anyone in the household have a dog allergy? Yes No if yes, please specifyHow would this be managed for a Purposeful Placement dog?Are ALL members of the household supportive of this application? Yes No Are there pets in the household? Yes No Pet type Add RemoveBreed Add RemoveAge Add RemoveNeutered? Add RemoveLive inside or outside Add RemoveSocialised with dogs? Add RemovePlease provide details of where the Purposeful Placement dog’s bed would be placed and/or where it would sleepPlease describe how the Purposeful Placement dog would be cared for when it requires grooming, feeding, veterinary care, removal of waste (i.e. Who will be responsible to physically do this).Please describe how and when the Purposeful Placement dog will be exercised.What time periods would the Purposeful Placement dog be left alone?Background InformationHas the applicant, or anyone in the household, been subject to a court order prohibiting them from the ownership of any animal? Yes No If yes, please provide detailsOtherWhat prompted this application for a Purposeful Placement Dog?Please share any other comments or information.This section requires you to review and sign important consent, privacy and release of information statements. Please have a support person with you if required and engage in any self-care you need to feel well. ADA is not a crisis service however, please contact Lifeline on 13 11 14 for emotional support or 000 in an emergency. Information Gathering, Confidentiality & ConsentThe Applicant: has reviewed the information and meets the criteria for an ADA Purposeful Placement Dog. understands that ADA will only accept Applications that are completed in full with supporting documentation submitted within two (2) weeks. understands that ADA reserves the right to advise that an Applicant is not suitable for an ADA Purposeful Placement Dog at any time throughout the application process. Information Gathering - The Applicant understands and agrees that: providing information about themselves, their family, and/or their support people is voluntary, and their decision to share personal information with ADA. personal information is gathered as part of ADA’s assessment, dog matching, contracts, training, program reviews, and general ADA program development and quality improvement. ADA may record portions of in-home suitability assessments (video/photos) to optimise our dog matching process. No images/footage will be captured without prior knowledge/consent at the time. personal information is kept securely, and all applicants are protected by the ADA Privacy Policy. ADA is committed to, and complies with, the appropriate legislation to keep information private and confidential, including the Australian Privacy Act 1988 (amended 2014). at any stage they are entitled to apply to access their personal information retained by ADA, subject to exceptions in the relevant legislation or by ADA management. quality improvement or evaluation findings undertaken by ADA may be made public (e.g. as a report or journal article). However, if findings are made public, the applicant, their family, and/or support persons will not be personally identified in any way. ADA is subject to audits from governing bodies such as Assistance Dogs International (ADI) and the National Disability Insurance Agency (NDIA/NDIS), and information may be reviewed for these purposes. ADA works with secondary bodies for ongoing research. ADA will seek permission to share personal information prior to the commencement of any research. Participation is optional and will not impact the application process. Confidentiality limits - All personal information gathered by ADA will remain confidential except when: it is subpoenaed by a Court, or disclosure is otherwise authorised by law. failure to disclose the information would, in the reasonable belief of an ADA staff member, place the applicant, an animal, or another person at serious risk to their life, health, or safety. prior approval has been obtained to disclose the information. I have read, understood, and agree to the points set out above.Name* First Last Signature*Date* DD slash MM slash YYYY Rights & ResponsibilitiesApplicant/Recipient Rights All Applicants will be considered regardless of race, gender, religion and/or sexual orientation. Applicants and, if successful, recipients have the right to be treated with respect and dignity in all interactions with staff, volunteers and other constituents of Assistance Dogs Australia. If successful, recipients have the right to receive an educational program to learn how to handle the dog at home. If successful, recipients have the right to receive a physically sound dog. ADA Dogs will be neutered or spayed prior to being placed. Recipient Responsibilities Recipient will be responsible for all associated costs, which include veterinary, feeding, worming, and grooming if they are successful and have taken possession of the Purposeful Placement Dog. Recipient are responsible for their travel and any associated costs for the purpose of training. Recipient must be responsible for the health and wellbeing of the Purposeful Placement Dog. Recipient must register their Dog with their local council. Recipients must inform ADA if they can no longer own the dog, prior to rehoming the dog. Assistance Dogs Australia’s Dogs Rights All animals within Assistance Dogs Australia’s programs have inalienable rights for the entirety of their life, including the following: The right to be cared for in a manner that meets ADA’s welfare standards The right to be well treated and not be mistreated, ill-treated or cruelly treated The right to positive and considerate training techniques The right to protection from physical, verbal and other attack The right to quality food, water and shelter indoors in the family home The right to proper veterinary care The right to adequate rest periods The right to adequate play periods I have read, understood, and agree to the points set out above.Name* First Last Initial*Date* DD slash MM slash YYYY Terms of Agreement Assistance Dogs Australia assesses applicants for suitability and merit. After completing an application there is no guarantee of acceptance. Assistance Dogs Australia reserves the right to advise applicants that they are not suitable for a dog at any time. Providing false or misleading information to Assistance Dogs Australia can result in dismissal from the program. If successful, the Purposeful Placement Dog will not be used by the applicant, or other party, for the purposes of begging, busking, or in the film, television or entertainment industry without the written consent of Assistance Dogs Australia. The applicant understands that upon successful completion of training, guardianship of the dog will be transferred from Assistance Dogs to the applicant. ADA’s program is voluntary, and the applicant has decided to participate in the program. The applicant understands that engaging with Assistance Dogs Australia may involve interaction and play with dogs, including physical contact, feeding, and grooming. Assistance Dogs Australia staff take all reasonable steps to ensure the safety of individuals and dogs. However, there are inherent risks associated with working with animals, such as scratches, swipes, knocks, bites, barking, zoonotic diseases, and presence of animal fur and saliva on your person. If successful, the recipient must be prepared to comply with the Terms of Agreement. I have read, understood, and agree to the points set out above.Name* First Last Initial*Date* DD slash MM slash YYYY Final checklistPurposeful Placement Dog Program Overview I have read and understand the information providedSignatureApplicant Information I have completed the applicant information in full and all information provided is true and correctSignatureConsent & Release of Information I have signed all consent & release of information formsSignature Click the blue box below to submit