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2024 Veteran Application
* Indicates required question
Email
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Your email
Contact Information:
First Name
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Your answer
Last Name:
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Your answer
Gender:
Male
Female
Clear selection
Date of Birth:
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MM
/
DD
/
YYYY
Street Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip:
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Your answer
Cell Phone Number:
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Your answer
Veteran Status:
Are you a U.S. veteran?
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Yes
No
What branch did you serve in?
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Your answer
Did you receive an honorable discharge?
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Yes
No
What was your rank at the time of discharge?
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Your answer
Veteran Disability Info
Date of Disability
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MM
/
DD
/
YYYY
Is your disability service related?
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Yes
No
Define your disability or limitations:
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Your answer
Define specific need(s) for a service dog. Please be specific.
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Your answer
Veteran Support: Primary Contact (Spouse/Partner/Family Member/Friend)
First Name:
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Your answer
Last Name:
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Your answer
Phone Number:
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Your answer
Email address:
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Your answer
Relationship to veteran:
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Your answer
Years known:
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Your answer
Medical Information
Doctor/Mental health provider name:
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Your answer
Is your mobility or condition limited? If yes, how?
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Your answer
Describe any hospitalizations you have had in the last three years:
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Your answer
Describe your current activity level:
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Low
Medium
High
What activities do you most enjoy?
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Your answer
Describe a typical day in your life:
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Your answer
What are your hopes and fears of receiving and living with a service dog?
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Your answer
Employment:
Employment Status:
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Full time
Part time
Self Employed
Retired
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
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Yes
No
Have you had a service dog before?
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Yes
No
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?
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Yes
No
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?
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Yes
No
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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Yes
No
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