Service Dog Application
If you or someone you know needs a Service Dog please fill out this application to the best of your ability.
Date
First Name of Applicant
Last Name of Applicant
Name of Parent or Guardian (if applicable)
Relationship to Applicant
Age of Applicant
Gender of Applicant
Address
Email
Phone Number
Occupation
How did you hear about us?
Family/Friends
Social Media
Other
Description of your disability(ies)
Please include specific information regarding your diagnosis, prognosis, and limitations. List all secondary physical and/or psychological diagnosis.
Description of your tasking needs
Please list the specific tasks you need a Service Dog to perform to mitigate your disabilities
Tasks required in the home:
Tasks required outside the home (in public, school, work, etc.)
Please select the devices you use, if any:
Power Wheelchair
Manual Wheelchair
Crutches
Walker
3-Wheel Electric Scooter
4-Wheel Electric Scooter
Cane
Other
What modes of transportation do you use?
Personal Vehicle
Taxi
Public Transportation (bus, subway, street car, etc)
Medical Transportation
Uber/Lyft
Bicycle
By Foot
Other
Household Information
Type of Home
Select an option
House
Apartment
Do you have a fenced yard?
Select an option
Yes
No
Who lives in the home?
Please list each person that lives in the homes including name, age, and relationship.
Are there pets in the home?
Select an option
Yes
No
Please list any other animals in your home including Name, Age, and Species.
I certify that the above information is true and complete to the best of my ability
Your Signature
*
Clear
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