Golden Opportunities for Independence (GOFI)
Application for Service Dog Recipients

Thank you for your interest in a GOFI service dog. Our Golden Retrievers are held to the highest standards of temperament and trainability, and each dog is trained specifically for its recipient’s needs. Our goal is to provide service dogs to those living with physical and psychological disabilities in order to provide greater independence and a better standard of living. GOFI trains dogs to assist with spinal cord injuries, diabetes alert, epilepsy disorders, anxiety disorders, and Post-Traumatic Stress Disorder.  

Please understand that applications are reviewed in the order that they are received. Because we strive to find the best match for each recipient, placement schedules may vary.  You can expect to hear from GOFI within two weeks, at which time an area coordinator will conduct a home visit.  We will then assess whether we have a dog that can meet your needs.

We encourage applicants to call us with any questions or concerns they may have.

Best Wishes,
The GOFI Family

Address:
323 High Street, Walpole, MA, 02081
Phone:
978-847-7870
Email:
gofidogs@gmail.com
RECIPIENT APPLICATION
Person Filling Out Application (if different from Applicant):
Primary Phone Number:
Address/City/State/Zip:
Email:
Applicant Name:
Emergency Contact Name
Emergency Contact Phone
Age of Applicant
Height and Weight
Applicant's Date of Birth
Does the Applicant Smoke?
Does Anyone in the Applicant's Household Smoke?
What is the applicant's normal daily level of activity?
Please describe the medical condition(s) for which the applicant is seeking a service dog.
Please describe any limitations the applicant experiences in everyday life.
Does the applicant have any learning disabilities or speech impairments?
Does the applicant use any assistive devices on a daily basis (i.e. wheelchair, crutches, hearing aids)?
Does the applicant have any safety measures that must be kept in place as a result of the applicant's diagnosis?
If yes, please explain:
Has the applicant ever had an aggressive outburst in which an animal or person was injured?
If yes, please explain:
What type of home does the applicant live in (apartment, condo, house, etc.)?
Does the applicant own or rent the home?
Does anyone in the applicant's home have allergies to dogs?
Please list all people residing in the applicant's home (name, age, relationship to applicant):
Does the applicant have a fenced yard?
If no, where and how does the applicant plan to exercise a dog?
Does anyone else in the household have a disability?
If yes, please explain:
Has the applicant or anyone in the home ever been convicted of a felony?
If yes, please explain:
Do any animals live in the applicant's home?
If yes, please list species and ages of animals:
Do the animals in the household get along with other animals?
Does the applicant have a veterinarian they currently use?
If yes, please provide the name of the clinic and veterinarian:
Do you have strong feelings about what traits you like or dislike in a dog?
If yes, please explain:
Is the applicant employed?
Applicant's Job Title:
Name of Employer
Employer Phone Number:
How many hours does the applicant work per day/week?
May we contact the applicant's employer?
Does the applicant attend school/university?
Name of School:
Address of School:
Phone Number of School:
May we contact the applicant's school?
How many hours of school does the applicant attend per day/week?
Would the applicant want the service dog to attend work or school with them?
Is the applicant able to take care of a dog on their own (i.e. walking, grooming, feeding, communicating with the dog, etc.)?
If no, who would help the applicant care for the dog?
Where will the dog stay when no one is home?
Will the dog be allowed to sleep in the applicant's bedroom?
If no, where will the dog sleep?
How do you plan to provide exercise for the dog? Fenced yard Leash walk Tie-out Allow the dog to run free
How do you plan to address the dog's need to go outside to eliminate? Fenced yard Leash walk Tie out Allow the dog to run free
Can the applicant afford yearly general veterinary care for a dog ($700-$1000/year)?
Have you ever received a service dog or applied for a dog from another organization?
Name of the organization (if yes):
Outcome of application (if yes):
Which of the following tasks would the applicant like the dog to help them with to make them be more independent (check all that apply)? Picking up dropped items Carrying items Turning on/off lights Retrieving the phone Poor balance in walking Emotional/Anxiety-related support Opening doors Getting up from floor Getting up from sitting on a chair Moving a wheelchair up a ramp Difficulty with stairs Difficulty with transitions/locations Other
Is the applicant's family/household supportive of the applicant having their own service dog?
Please describe the applicant's current support system. Who would care for the dog if the applicant were to be injured, hospitalized, or otherwise unable to care for the dog?
Is the applicant willing to travel to Golden Ridge Farm (323 Hight St., Walpole, MA) at least twice a month for training sessions, and does the applicant have transportation?
Comments or questions:
Plese provide contact information (full name, phone/email, and relationship to applicant) of two non-family personal references:
All applicants: Please provide a letter from a medical professional stating that the applicant has a diagnosed medical condition that could benefit from being partnered with a service dog. File must be 10MB or less.
Applicants seeking service dog for psychological condition(s): Please provide a letter from a mental health professional stating that the applicant is receiving ongoing treatment for the applicant's condition, and poses no threat to a service dog (if the dog is for a psychological condition). File must be 10MB or less
By signing below, I hereby acknowledge I have read the above application and I junderstand that Golden Opportunities for Independence reserves the right to deny service to an applicant for any reason, including but not limited to failure to meet the established criteria for receiving a service dog or requesting services we do not provide. I do hereby agree to hold free from any and all liability Goldent Opportunities for Independence and its members and officers. My family, members of my household and I waive the rights and claims for damages and injuries, which may come from my connection and participation with GOFI.
Signature of Applicant:
Signature of Guardian (if applicant is a minor):
Which of the following tasks would the applicant like the dog to help them with to make them be more independent (check all that apply)? Picking up dropped items Carrying items Turning on/off lights Retrieving the phone Poor balance in walking Emotional/Anxiety-related support Opening doors Getting up from floor Getting up from sitting on a chair Moving a wheelchair up a ramp Difficulty with stairs Difficulty with transitions/locations Other
Submit