Assistance Dogs Australia
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Select Page

Purposeful Placement Application Form

"*" indicates required fields

Purposeful Placement Dog Program Application Form

Applicant Personal Information

Name*
Pronouns

DD slash MM slash YYYY
Do you personally know any ADA staff member*

Contact Information*
Emergency Contact*
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 Circumstances

Type of Home

Is there a yard?
Is the yard fully fenced?
Who does the applicant live with?
Please provide details of all people living in the household (even temporarily)
Name
Age
Relationship
Disability/mental health/behavioural issues

Does anyone in the household have a dog allergy?
Are ALL members of the household supportive of this application?
Are there pets in the household?
Pet type
Breed
Age
Neutered?
Live inside or outside
Socialised with dogs?

Background Information

Has the applicant, or anyone in the household, been subject to a court order prohibiting them from the ownership of any animal?

Other

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 & Consent

The 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*
Clear Signature
DD slash MM slash YYYY

Rights & Responsibilities

Applicant/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*
Clear Signature
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*
Clear Signature
DD slash MM slash YYYY

Final checklist

Purposeful Placement Dog Program Overview

I have read and understand the information provided

Clear Signature
Applicant Information

I have completed the applicant information in full and all information provided is true and correct

Clear Signature
Consent & Release of Information

I have signed all consent & release of information forms

Clear Signature
Click the blue box below to submit