Veteran/First Responder Service Dog Application
Email *
Contact Information:
First Name
 *
Last Name:
 *
Gender:
Clear selection
Date of Birth:
 *
MM
/
DD
/
YYYY
Street Address:
 *
City:
 *
State:
 *
Zip:
 *
Cell Phone Number:
 *
Veteran Status:
What program are you applying for? *
Veteran: What branch did you serve in. Rank, deployment/combat?
First Responder: Where and when were you employed. Any defining event pertaining to your disability?
 *
Did you receive an honorable discharge? *
Please describe your limitations and or disability
Date of Disability *
MM
/
DD
/
YYYY
Is your disability service or job related? *
Doctor/Mental health provider name: *
Have you had a service dog before? *
Define specific need(s) for a service dog.  Please be specific. *
Applicant Support: Primary Contact (Spouse/Partner/Family Member/Friend)
Applicant Supporter: First Name: *
Applicant Supporter: Last Name:
 *
Applicant Support: Phone Number: *
Applicant Supporter: Email address: *
Relationship to applicant: *
Years known: *
Describe any hospitalizations you have had in the last three years: *
Describe your current activity level: *
What activities do you most enjoy? *
Describe a typical day in your life: *
What are your hopes and fears of receiving and living with a service dog? *
Employment:
Employment Status: *
If employed, have you discussed this application with your employer to ensure they are supportive of the idea of you always having a service dog at your side *
Are you willing and able to attend weekly classes at our training location and outings required to certify your dog as a fully-trained service dog? *
Are you willing and able to attend required ongoing monthly classes, outings, and annual exams to maintain your dog's certification as a fully-trained service dog? *
If selected for our program, are you able to financially provide food, heartworm prevention, flea/tick control, veterinary care, and grooming for a service dog? (Costs are approximately $65/month for basic needs). *
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