SD Gunner Fund Service Dog Application 2022

Part IV: Pets
Do you currently have any pets in your home?

YesNo
If yes, please describe the number, type, gender, breed, and ages of all pets
Have you ever had a dog before?

YesNo
If yes, please tell us how you were able to care for the dog.
Is anyone in your home allergic to animals?

YesNo
If yes, please explain
Does anyone in your home have a fear of dogs?

YesNo
If yes, please explain

Emergency Contact Form

This form MUST be completed by all staff, students, volunteers, and graduates. In the event of emergency, the SDGF will make a good faith effort to contact the primary contact person you have listed. If SDGF is unable to reach your primary contact, an attempt will be made to reach your secondary contact. It is recommended that the primary contact person you have listed also has power of attorney over medical decisions for your. In the case of a minor who is connected with the SDGF youth program, the primary contact person listed MUST be either a parent or legal guardian.
Primary contact (in the case of a minor, this MUST be a parent or legal guardian)

First NameLast Name
Relationship to applicant
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Secondary contact

First NameLast Name
Relationship to applicant
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.

Consent for Medical and/or Emergency Treatment
I,blanks, hereby voluntarily give consent give limited consent DO NOT give consent
If limited consent, please explain
to SD Gunner Fund, Inc. to seek medical care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by medical doctors, hospitals or their authorized designees, as may in their professional judgment to be necessary to provide for the medical, surgical, or emergency care of:

First NameLast Name
Relationship to patient
In the event that I am (or my dependent is) injured or ill while participating in organized events with SDGF, I hereby give permission to SDGF to provide first aid for myself or my dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility.

In making medical decisions on my behalf for the benefit of myself or my dependent, I direct that SDGF attempt to notify my next of kin or designated contact person(s). If SDGF cannot reach my primary contact, then I understand that the SDGF will attempt to notify my secondary contact. However, if medical care becomes essential, I give permission to SDGF to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital, or their authorized designee. In furtherance of any treatment decisions to be made by SDGF on my behalf for the benefit of myself or my dependent, I authorize SDGF to request, obtain, review and inspect any and all information bearing upon myself or my dependent's health and relevant to any such decisions to be made respecting such treatment.

I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment for the condition of myself or my dependent and that I am solely responsible for all costs associated with the care and treatment rendered to myself or my dependent.
Health insurance information
Primary insurance carrier
Health insurance policy # and group #
Name of insured
Relationship to patient
Secondary insurance carrier
Health insurance policy # and group #
Name of insured
Relationship to patient
Name of Primary Care Physician
Office Phone Number
Please enter a valid phone number.
Doctor's Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of dentist
Office Phone Number
Please enter a valid phone number.
By signing this consent/non-consent document I acknowledge that I have carefully reviewed this information and fully understand the implication of this consent/non-consent form. I acknowledge that the information presented is up to date, accurate, and true to the best of my ability. I understand and agree that in the event that any of the information changes I will submit a notarized statement to that effect to SDGF within 10 business days of such changes. Signature of applicant below (or parent/guardian if applicant is a minor).

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Today's Date

MonthDayYear
Date
Relationship to patient

Notice of Privacy Practices

SDGF Program participants and volunteer staff are entitled to privacy of their personnel files. The only exception to this policy are cases when the participant is a minor, where prior express consent has been granted in writing, for the sharing of protected information of in cases where SDGF may be required to share protected information as part of ongoing legal proceedings or investigations. The terms and conditions of our privacy policy are presented here for you information. Protected information includes but is not limited to any information in your personnel file including health information as well as attendance records, demographic data, and all progress notes.
Privacy of Health Information

SDGF is required to maintain medical history forms as well as signed consent/non-consent forms for medical treatment for each program participant. In those cases where consent has been granted for medical treatment, SDGF is authorized to share medical information about you with emergency health care providers, on a need-to-know basis. For the purposes of this discussion, the following terms are defined:

Treatment: this means the provision, coordination, and/or management of health care and related services by one or more health care providers. An example of this would be the disclosure of your Protected Health Information (PHI) to providers outside of SDGF who are connected to your health care treatment.

Payment: this refers to reimbursement for any services that are related to your treatment, and also including but not limited to confirmation of coverage, billing services, or collection services and utilization review.

Health Care Operations: this includes the business aspects of medical practice, such as quality assessment/control, auditing functions, cost-management analysis, and customer services. It is also understood that SDGF may be required to disclose protected health information about you to nurses, therapists, students, and other health care personnel who are involved in your care and treatment.

SDGF will, from time to time, be requested to participate in ongoing research studies in the service dog industry. For the purposes of this research, SDGF may release de-identified, aggregate data regarding our program participants.

Legal authority to make health care decisions for minors or others.

Usually, the health information rights for a minor are extended to the minor's parents or legal guardians. There are, however, exceptions to this rule. For example, some health care decisions may be provided for a minor without the consent of a parent or guardian under implied consent, in cases where a delay in treatment could have devastating consequences.

SDGF may, without prior consent, disclose protected health information to carry out treatment, payment, or health care options to a minor under the following circumstances:
- In an emergency treatment situation, if we attempt to obtain such consent as soon as is reasonably possible after delivery of such treatment
- If we are unsuccessful in reaching the parent/guardian to obtain consent, or in cases where we are presented with a significant communication barrier and determine, in our professional judgment, that your consent to treatment is clearly implied by circumstances
- To avert a serious threat to the health or safety of yourself or others in the event that any SDGF staff becomes aware of a credible threat that you (or your dependent) intend to cause harm to yourself or others, we will take the necessary steps to notify the authorities to prevent such threat from becoming a reality.
- Student interns- SDGF reserves the right to share information, as needed, with students who are interning with SDGF and may be required to supervise any activities in which you may participate. In the event that you object to information sharing with an SDGF intern, you have the right to object in writing to prevent the sharing of such information.
- Photo releases are obtained for all students, and all photos and/or videography that are obtained during your participation in any of our programs are the exclusive property of SDGF. SDGF reserves all rights to these photos/videography. In the case of students who change their mind and no longer wish to be photographed, you may submit written notice of such decision and no further images will be obtained. All images taken prior to the date of this notice, however, continue to be the property of SDGF and may be used for publicity or training purposes in accordance with prior written permission (per the terms of the Photo Release form)
- Military-SDGF may disclose your protected health information as required by military command authorities if you are in the armed services.
- Workers Compensation-SDGF may disclose your protected health information if required by workers compensation or similar programs to the extent necessary in order to comply with laws relating to workers compensation or similar programs that provide benefits for work-related injuries or illness, as established by law.
- Public health entities-as required by law the SDGF may disclose protected information about you to the Georgia Department of Public Health in order to:
  - Prevent or control disease, injury, or disability;
  - Report suspected child abuse or neglect;
  - Notify a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or donation;
  - Notify the appropriate government authority if we believe that a client may have been the victim of abuse, neglect, or domestic violence. We will only make this disclosure subject to certain requirements when mandated and authorized by law;
  - Notify the appropriate authorities in cases where a program participant informs SDGF that they are intending to harm, neglect, or abuse themselves or others, in order to protect the other person and our client.
- Lawsuits and legal disputes- SDGF may disclose protected health information about you in cases of legal disputes to the extent that we are required to cooperate in any ongoing investigations.
SDGF is required to inform you of our privacy policies as well as our legal duties as they pertain to your protected information. This notice is prepared and effective as of January 1, 2022, and we are required to abide by the terms and conditions of this notice. We are also required to provide you with written notice of any revisions that may occur during the time that you are involved as a program participant with SDGF. If you believe that your privacy has been violated, you may contact one or both of the following departments:

SD Gunner Fund, Inc. (SDGF)

24 Cheney Court, Richmond Hill, GA 31324

615-804-3533

OR

Office of Civil Rights; U.S. Department of Health and Human Services

1301 Young St. Suit 1169 200 Independence Ave. SW

Dallas, TX

214-767-4056

When contacting us, please provide us with as much detail as possible so that your complaint may be fully investigated without delay. You will not be penalized for the filing of any complaint. A signed copy of this page MUST be returned to SDGF within seven business days of receipt.
I, blanks , acknowledge that the SDGF has provided me with a written copy of their privacy practices on this date of Date
I understand that information regarding program participants is privileged and will not be shared with anyone outside of SDGF without my written expressed permission with the exceptions that have been noted in this document. I acknowledge and fully understand the information that has been presented to me in this document. Signature of program participant below (or parent/guardian, if minor)

Clear
Date

MonthDayYear
Date
Printed name of above

Notice of Costs and Financial Resources
Military veterans are eligible for services at no final cost.

Those who are applying:
- If you have elected to apply for a dog that will be trained specifically for your disability, we ask that you support SD Gunner Fund through volunteer hours and/or helping fundraise $2,500 for your service animal
- All SDGF Service Dogs remain property of SDGF at all times. Recipients are never allowed to sell, give away, or any other way discard of SDGF animals. If you should do so, SDGF has the legal right to pursue maximum charges against you.
All others:
The average cost of a service animal is $15,000-$25,000, depending on tasks trained. While you are not responsible for this cost, as a non-profit we would appreciate your support through personal fundraising efforts and volunteering in our "Pay it Forward" Program. You will not be eligible for participation as a student trainer, and your ability to be awarded a dog will depend on your place on the waitlist. SDGF has a policy that military veterans, first responders, and special needs children will be moved to the front of the list, so your place on the list at any time may change depending on the number of applications we have received.
How are you able to support SD Gunner Fund as a program recipient? (select all that apply)

Fundraising $2,500Volunteer HoursI'm not able to support SD Gunner Fund at this timeOther
How much are you willing to help SD Gunner Fund fundraise to help off-set the cost of your service animal?
How many hours per month are you willing to volunteer?
What areas are you interested in volunteering with? (select all that apply)

TrainingSDGF Fundraising Event PlanningOutreach/CommunicationsNot interestedOther

General Release of Liability Statement
I, blanks hereby release any liability(ies) or claim(s) in participating in any activities or services sponsored by the SDGF organization. I acknowledge that I assume the risks and responsibilities in such participation and hold SDGF harmless for any injuries or liabilities incurred or sustained in my participation. It is understood and agreed that, by acknowledging and signing this release, I irrevocably, unconditionally and completely release and forever discharge SDGF, and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents from any and all losses, demands, damages, obligations, liabilities, actions, causes of action, debts, suits, judgments and all claims of any kind or nature whether known or unknown, fixed or contingent, arising directly or indirectly from, as a result of or in connection with, or otherwise relating in any manner to any claims of liability, that were alleged, or could have been alleged, against SDGF, and all of its principals, officers, heirs, representatives, successors, subsidiaries, assigns, affiliates, shareholders, partners, employees, former employees, attorneys, insurers, and/or agents, that may in the future develop from or be caused directly or indirectly from any actions causing such liabilities. I acknowledge that I provide this release voluntarily and knowingly.
Signature of Participant (or parent/guardian, if participant is a minor)

Clear
Date

MonthDayYear
Date
Printed Name of Participant (or parent/guardian, if participant is a minor)

SDGF Code of Conduct
CODE OF CONDUCT FOR STUDENTS, STAFF, AND VOLUNTEERS

SDGF has established minimum standards for the behavior of all students, staff, and volunteers, and all individuals affiliated with SDGF are expected to live up to these standards at all times. It is understood that whether in the classroom, office setting, or out in public at events, you are serving as an ambassador of goodwill for SDGF and your behavior reflects on the entire organization. Standards for behavior include the following:

HONESTY, INTEGRITY, AND PUBLIC PRESENTATION

Individuals affiliated with SDGF shall at all times:
1. Be courteous and respectful of the feelings and needs of those around them
2. Be supportive of those with special needs and offer assistance as needed
3. Be honest
4. Treat others as they would wish to be treated
5. Use appropriate language
DRESSCODE

Individuals who participate in SDGF sponsored public events shall:
1. Be clean and well-groomed, and free of any offensive odors
2. Avoid the use of perfumes and colognes as these may precipitate respiratory problems for individuals with chronic illness
3. Dress appropriately for the occasion; clothing must be in good repair; no torn jeans, low cut shirts, sheer blouses, or crop tops
4. Wear their name badge at all times when working at an event
ETHICAL STANDARDS

SDGF has a zero-tolerance policy for untoward behaviors and individuals who are affiliated with SDGF shall at all times:
1. Refrain from bullying behavior and report any perceived incidences to a supervisor immediately
2. Refrain from use of illicit drugs
3. Arrive sober to all events and avoid the use of alcoholic beverages when working at SDGF sponsored events
INTERACTIONS WITH SDGF YOUTHS

SDGF allows youths the opportunity to participate in our program, and all individuals who are affiliated with SDGF must be aware at all times of the impact that their behaviors will have on impressionable young people. Standards for interactions with SDGF youth members include the following:
1. At no time will a staff or volunteer member be alone with a youth; a supervisor must be present at all times
2. At no time will a staff or volunteer transport a student to or from an event in their personal vehicle without written permission of the parent/guardian and knowledge of an SDGF supervisor
3. Physical contact with any youth participant, other than a traditional handshake, is strictly prohibited
4. Staff, students, and volunteers are expected to be positive and supportive and present our youth to the public in the best possible light at all times
CODE OF CONDUCT FOR SD GUNNER TEAMS

SDGF has established minimum standards for service dog teams, and the team is expected to live up to these standards at all times. This includes behaviors observed during testing and extends to conduct in public during the team’s entire working life. Note that the focus here is on the behavior of the team, not merely the dog. These standards include the following:

HEALTH, WELLNESS, AND SAFETY

The handler shall provide:
1. Monthly heartworm treatments.
2. Monthly flea and tick treatments if recommended by a veterinarian.
3. All required vaccinations.
4. Baths, brushing and grooming to keep the dog clean and free of any offensive odors.
5. Proper oral care.
6. Regular nail trimming.
7. Current county license tags are prominently displayed on the collar.
8. A name tag with a current phone number is displayed on the collar.
9. A clean program vest in good repair with an ID badge and emergency contact card displayed in the pocket to be worn at all times while in public.
10. Thermal working booties to protect against injury from excessive temperatures or sharp objects if recommended by a veterinarian.
11. Working equipment that is properly fitted and in good repair, including a collar, a leash that is no longer than 6 feet in length (retractable leashes are not permitted), and a harness (if applicable); backpacks are not permitted on the dog.
12. Adequate food and hydration; must carry a portable water bowl when working.
13. Provide required and adequate fencing: All residences must have a fenced-in area for dogs to exercise and relieve itself
14. Service Dog must be on a leash at all times when outside the physical structure of the home
TRAINING
The dog shall be trained to:
1. Perform at least one service-related task to mitigate the disability of the handler.
2. Obey commands on the first attempt at least 90% of the time, except in cases of intelligent disobedience.
3. Maintain a good heel on a leash, harness, or Gentle Leader.
4. Lie quietly beside the handler or under a seat without creating an obstacle to others.
5. Urinate or defecate only in appropriately designated places.
The trainer shall:
1. Ensure that the selected service tasks are appropriate for the dog.
2. Use only positive reinforcement techniques that have been approved by the SDGF for service dog training.
3. Be consistent in enforcing commands.
4. Ensure that the dog is within two feet of them at all times except when a task requires a greater distance.
5. Ensure that the dog has adequate space in order to avoid injury to the dog or others in public.
6. Provide regularly scheduled rest breaks for the dog.
7. Provide all needed maintenance for the dog while in the trainer’s care (food, veterinary, heartworm/flea, etc...)
PUBLIC BEHAVIOR

The dog shall:
1. Not solicit attention from strangers;
2. Be able to work quietly in public without barking, whining or otherwise creating a distraction.
3. Not growl, snarl or demonstrate any aggression towards people or other dogs.
4. Not solicit or steal food items from the general public.
5. Urinate or defecate only in appropriately designated places.
The handler shall:
1. Set and enforce consistent boundaries and shall prevent members of the public from petting or greeting the dog while it is working.
2. Respond politely and appropriately to public inquiries and challenges at all times.
3. Maintain control over their dog at all times.
4. Remain alert for signs of danger and shall remove the dog from dangerous situations when necessary.
5. Provide the dog with adequate food and hydration, but shall not feed the dog in designated public dining areas.
6. Provide regularly scheduled rest breaks for the dog.
Note: At all times, the final responsibility for all aspects of care, training, and public behavior rests with the handler.

Social Media Conduct: At all times all recipients and volunteers of SD Gunner Fund shall refrain from giving bad reviews or posting (or having a third party post) any derogatory, inflammatory, or slanderous statements about SD Gunner Fund via ALL social media channels. All conflicts or frustrations will be handled professionally and courteously by all parties involved.

Agreement to Abide by SDGF Code of Conduct
I, blanks , hereby acknowledge that I have received the information on the SDGF Code of Conduct.
I understand and agree to abide by all SDGF guidelines, as well as all rules and regulations of SDGF during the time that I am in training with SDGF. I understand and agree that if at any time, I am found to be in violation of the SDGF Code of Conduct, I will be dropped from the program. I understand and agree that should this action become necessary, I am not entitled to a refund for any or all monies that have been fundraised up until that time.
I understand and agree that should I have any questions regarding the standards and ethics or rules and regulations as they have been presented in the application packet, I may contact SDGF by phone at 615-804-3533, or by email at: sdgftraining@gmail.com to have my questions answered.
I acknowledge that I have reviewed the information presented to me and have no further questions. I understand the information as presented and agree to abide by the SDGF Code of Conduct. This includes the time I spend in training, as well as my working life with my SDGF service dog.
Signature of Applicant (or parent/guardian if applicant is a minor)

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MonthDayYear
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Printed name of applicant (or parent/guardian if applicant is a minor)

Photograph & Video Release Form
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:
- conference presentations
- educational presentations or courses
- informational presentations
- on-line educational courses
- educational videos
- social media/publicity
By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recordings for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio, or video recordings collected as part of the sessions listed on this document only.
By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes. Signature of applicant below (or parent/guardian, if minor)

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Date

MonthDayYear
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Printed name of applicant (or parent, guardian, if minor)

Consent to Use Testimonial
This Consent to Use Testimonial confirms that SD Gunner Fund (Company) has the right to use my testimonials, which may include the following: (a) my personal testimonials, in whole or in part, regarding Company products, customer service, or any other comments; and (b) my full name and the city and state in which I live (Testimonials). I agree as follows:

1.     I grant Company the right to use my Testimonials without compensation.

2.     I understand that the Testimonials may appear in connection with (a) Company website and social media channels; (b) publications for Company related to advertising, marketing, information and education, or any other publication Company may deem useful and appropriate; and (c) all electronic and print media of Company or its subsidiaries and affiliates.

3.     I understand that Company may edit the Testimonials for clarity or consistency, if deemed necessary by Company.

4.     I acknowledge that Company has made no promise or representation to me that Company is obligated to use the Testimonials, and I understand that Company has sole discretion to determine whether or not to use my Testimonials.

5.     I am over the age of eighteen years old.

6.     I release Company from any claims and expenses arising from the use of my Testimonials as herein specified.
IN WITNESS WHEREOF, I acknowledge and consent to the terms of this Consent to Use Testimonial as of blanks , 20 blank .
Signature

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Name

First NameLast Name
Should be Empty:

SD GUNNER FUND

Part 1 : Personal Information

Part II: Family/Living Situation

Part III: Employment Situation

Part IV: Pets

Part V: Service to Community

Part VI: Acknowledgement and Signature

Medical History Form

Part 1: Personal Information

Part II: Past Medical History

Part III: Disability Information

Emergency Contact Form

Consent for Medical and/or Emergency Treatment

Notice of Privacy Practices

Notice of Costs and Financial Resources

General Release of Liability Statement

SDGF Code of Conduct

Photograph & Video Release Form

Consent to Use Testimonial