Registration form PAWS

Information parents

First Name *

Last Name *

Address (street and nr.) *

City *

Postal Code *

Telephone - GSM *

E-mail *

If other, please explain *

First Name *

Last Name *

Date of Birth *

MannelijkVrouwelijk

Description of the ASD(Autisme Spectrum Disorder) *

At which age the ASD was diagnosed? *

Name psychiatrist/doctor who diagnosed *

VerballyNon-verbally

If other, please explain *

YesNo

If yes, please provide name, age and gender *

Do you have training experience with dogs? If yes, which experience: puppy classes, obedience, ... and name of school *

Information related to your dog: breed, age, gender, social behaviour, *

Since how long has your dog been with your family and where did you purchase him? *

Bent u met uw hond naar de hondenschool geweest? Indien ja: puppyklassen, gehoorzaamheid, … en gegevens hondenschool. *

Did your dog ever show symptoms of agressive and/or fearfull behaviour? If yes, please provide us with more information. *

Explain briefly why you think your dog would be suitable for the PAWS programm. *

Are you considering purchasing a puppy or an adult dog? If yes, do you have an idea of the breed you would take? *