Residential Companion Dog Application



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RESIDENTIAL FACILITY COMPANION DOG APPLICATION

SECTION 1

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Thank you for requesting a residential companion dog application. The Canine Partners for Life residential companion dog program was established in 1996 to provide well trained companions to reside within residential facilities for the elderly or disabled. A residential companion dog lives within the facility, becoming an integral member of the community. In addition to visitation, the dogs are frequently incorporated into speech/language, physical and occupational therapies.

Dogs chosen for the residential companion dog program complete one year of training within a volunteer puppy home and are obedience trained and socialized in the same manner as a full service dog. At the end of the first year a residential companion dog is then placed in the home of a volunteer trainer who works closely with CPL trainers to focus on skills needed specifically for the facility’s placement. Dogs placed within the facility are typically 1 ½ years old.

Facilities requesting a residential companion dog need to complete an application and participate in an interview at Canine Partners for Life. In addition, visits will be made by CPL staff to the facility. A central, supervisory staff member needs to be involved within this entire process. When the decision has been made that CPL will be able to service the facility’s needs, a dog will be chosen based on those needs. The typical waiting period is six to eighteen months. When the dog’s training is complete a staff member from each shift at the facility, including the supervisory level contact person, need to attend four training sessions before placement will be made. For the duration of the placement there must be a trained staff member on each shift. This training session will focus on obedience skills, visitation skills and health care skills.

There is a $25 non-refundable processing fee that must be included with the application.

CPL provides regular follow-up phone calls and visits to the facility following placement and staff trainers are available for consultation at any time. The facility is required to have one staff member attend at least 6 classes at the CPL facility per year throughout the entire placement. Failure to attend the required classes per year may result in the facility returning the dog. Regular preventive and as needed veterinary care in addition to all grooming and food expenses are the responsibility of the facility.

SECTION 1 CONTINUED

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Canine Partners for Life is an accredited member of Assistance Dogs International. CPL respects the privacy of its applicants and recipients and all information is kept confidential although files may be periodically reviewed by accreditation agencies to ensure CPL’s commitment to the highest standards of excellence in the assistance dog industry.

Canine Partners for Life conducts its business and acceptance process in a manner that will not discriminate against anyone on the basis of race, color, religion, gender, national origin, age, the presence of mental or physical disability, sexual preference, life expectancy, or whether the individual is a disabled veteran or veteran of any era. It is Canine Partners for Life’s policy to treat everyone who comes in contact with the organization with respect and dignity at all times.

At no time will Canine Partners for Life require applicants, students, or graduates to participate in fundraising or marketing activities.

I have read, understand, and agree to SECTION 1 of this application (please initial): ____________

SECTION 2

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

What to expect when you apply for a residential companion dog:

• To travel, at your expense, to CPL for an interview.  The Executive Director or CEO of the facility and any key staff involved should attend the interview.

What to expect following the interview:

• To create a care plan for the dog which will include: care-givers positions, procedure for night and weekend care, plan for the dog to be taken off of the premises for rest and relaxation, plan for controlling treats, plan for routine and emergency veterinary care, etc. 

What to expect if accepted to waiting list:

• CPL staff members will visit the facility for a full tour.

• To wait approximately six to eighteen months to be matched with a dog.

• Five staff members (additional staff members are welcome) will need to attend training classes and orientation at the CPL facility.  This must include at least three weekday staff, two weekend staff members, one staff member from each shift, as well as the facility coordinator for this program.  When a trained staff member leaves the facility or program, a replacement must be trained within 60 days.  These five staff members will attend four training classes and orientation before a dog will be placed in the facility. One of these five individuals must be designated as the coordinator of the facility’s Residential Companion Dog Program.

• Any staff member wishing to take the dog home for rest and relaxation must complete the CPL training listed above. 

What to expect when a dog is selected:

• To purchase basic supplies for the dog - cost approximately $200.

• For the potential dog to make several short visits to the facility before a final placement decision is made.

• On the day of placement, to schedule several hours for CPL staff and facility staff to meet to discuss your dog, receive instructions on training and dog care, and for a training session. 

• To provide a requested $600 donation to CPL at the time of placement.

• Each handler will receive a copy of the residential dog contract and a copy will be placed in a designated area of the facility.

What to expect after your placement:

• The dog and a handler must attend six training classes at the CPL campus per year for the duration of the placement.

• Follow-up with a CPL trainer via phone or email - daily for the first week, weekly for the first month, and monthly for the first 6 months of the partnership.

• Monthly written follow up reports must be provided to CPL for the first year, including a daily log of the dog’s activities. After the first year these reports are required once every 6 months for the active working life of the dog.

• To allow an adjustment of approximately one to two months for your dog to become acclimated to your facility.

SECTION 2 CONTINUED

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

What to expect after your placement continued:

• To attend a mandatory CPL graduation ceremony. This allows the volunteers and donors involved in your dog’s training to be acknowledged.  Graduation is held twice annually on Sunday afternoons in July and November.  Your dog should wear any training aids provided at the time of placement to graduation. 

• Follow up training support is always available from CPL staff. 

• To maintain current veterinary health care according to CPL guidelines. Other health responsibilities/expenses include monthly heartworm preventives, flea preventives, necessary vaccinations, grooming and emergency veterinary care. 

• The dog must be fed one of the CPL approved foods. Food will cost approximately $60 per month.

• The dog’s weight will be closely monitored.  Excessive weight gain may result in the mandatory return of the dog to CPL.

• To join the CPL family for life!

What to expect from your dog:

• Residential companions are well socialized pets with reliable housebreaking and good basic obedience.  They are not trained to perform physical tasks such as retrieval.

• Residential companion dogs do not have public access under the Americans with Disabilities Act and may not be represented as service dogs for access to public facilities and housing.

• Residential companion dogs must always be held on leash or kept in a securely fenced area with direct supervision when outdoors.

• Residential companion dogs should be under direct staff supervision when interacting with residents. 

I have read, understand, and agree to comply with SECTION 2 of this application

(please initial): _______________

SECTION 3

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Address:__________________________________________________________________________________

__________________________________________________________________________________________

County:___________________________________________________________________________________

Primary Contact Person: ________________________________Office Phone:__________________________

Cell Phone: ____________________________

Email: _______________________________

Facility Director: ______________________________________ Office Phone:__________________________

Cell Phone: ___________________________

Email: _______________________________

Facility Fax Number: ________________________________________________________________________

Number of Staff at this facility: _________________________________________

Number of residents at this facility: ______________________________________

Does your facility provide (please circle):

Speech/Language Therapy yes no

Physical Therapy yes no

Occupational Therapy yes no

Does your facility have other pets?____________ If yes, what kind?_________________________________

Upon mentioning the idea of a residential companion dog to staff and residents, have you had any resistance or objections?_______ If yes, please describe concerns:

__________________________________________________________________________________________

__________________________________________________________________________________________

SECTION 3 CONTINUED

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Please list the names of all the Executive Directors over the past ten years along with the duration in their position.

_________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Does your facility utilize any type of restraint device with its residents?_________ If yes, please describe, in detail, the types of restraints used and under what circumstances.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Does your facility use a code alert or similar system to notify staff if an individual has left the building?

__________________________________________________________________________________________

In what area of the facility do you anticipate the residential companion dog living?

__________________________________________________________________________________________

__________________________________________________________________________________________

What staff person will provide direct supervision of the residential companion dog?

__________________________________________________________________________________________

Who will be responsible for taking the residential companion dog to the veterinarian, providing bathing, nail trimming and ear cleaning?

__________________________________________________________________________________________

SECTION 3 CONTINUED

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Who will be responsible for the feeding, watering, walking (5 times per day) and daily brushing of the residential companion dog?

__________________________________________________________________________________________

Have any of the staff members who will be in direct contact with the dog ever been convicted of a misdemeanor, summary offense, or felony related to the abuse, mistreatment, neglect or harm to animals? ______________Yes _______________No

If yes, describe in detail including the state and date in which the conviction was made: ___________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Who referred you to CPL? ____________________________________________________________________

I have read SECTION 3 of this application and to the best of my knowledge this information is true and correct.

Signature – Facility Director:________________________________________________________________

SECTION 4

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Please include with the application the following:

1. PROMOTIONAL MATERIAL (brochures, newsletters, etc.) describing your facility.

2. A LETTER FROM A LOCAL VETERINARIAN OF YOUR CHOICE saying that they will be caring for the dog’s health and will cooperate with CPL’s follow up when we ask to review the dog’s records. We will make arrangements to have the dog’s health history sent to your vet.

3. A BRIEF ESSAY explaining why you feel that a residential companion dog will be

beneficial and therapeutic for your facility. Also include how you anticipate utilizing the

resources of the dog and what specific programs you expect to fulfill this.

4. LETTERS INDICATING SUPPORT for the Residential Companion dog placement from the facility’s Executive Director, Director of Nursing, Facility Manager, and President of the Board of Directors.

5. $25 NON-REFUNDABLE APPLICATION PROCESSING FEE

SECTION 5

Facility Name: ________________________________________________Date: _____________________

Representative of Facility (name and title): __________________________________________________

Canine Partners for Life

Complaint Policy for Non-employees

Any non-employee (volunteer/applicant/student/recipient/donor) who has a grievance concerning CPL practices has the right to file a complaint according to procedures outlined in this policy. Grievances may include, but are not limited to, a perception of violation of rights; quality of service; discrimination based on category of race, age, disability, etc.; or other matter.

Complainants are treated with dignity and respect at all times, regardless of the nature of their complaint. They will not be discriminated against, harassed, intimidated, or suffer any reprisal as a result of filing a complaint or participating in an investigation of a complaint. If an individual feels that he or she is being subjected to any of the above, that person has the right to appeal directly to the Executive Director.

Affected parties should attempt to resolve the problem informally as soon as possible. Volunteers should discuss issues with the Volunteer Coordinator, donors with the Director of Development, and applicants/students/recipients with their trainer. If a solution cannot be reached, the person may present a formal complaint, in writing, to the Executive Director. Following the same protocol, complaints about the Executive Director should first be brought to her attention and then to the Board President if necessary. The President may be reached through CPL’s mailing address. Formal complaints and responses to them will be documented and kept on file.

All complaints are handled in a timely manner. As a goal, CPL attempts to resolve a complaint within 20 working days from the time of its initiation. If an extension of the time limit becomes necessary, all involved parties will be notified.

I have read, understand, and agree to SECTION 5 of this application:

Signature – Facility Director:________________________________________________________________

Return this complete application along with the items listed on page 8 to the address noted below. Please allow 2-3 weeks for processing. If you have further questions regarding the Canine Partners for Life application or residential companion program, please call (610) 869-4902 x 212.

Canine Partners for Life, P. O. Box 170, Cochranville, PA 19330

( info@ ( Fax (610) 869-9785

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