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Owner-Handled Application
First name
*
Last name
*
Date of Birth
*
Month
Month
Day
Year
Email
*
Phone
*
Address
*
Is this dog for a minor?
*
Is this dog for a military veteran? If so please list disability rating:
*
Tell us about yourself:
*
Please explain your disability/diagnosis that you are wanting assistance with:
*
Are you currently using any medical devices or medications for assistance? If so please list what you're using:
*
In detail explain what daily activities you are wanting the dog to assist you with:
*
If you have a dog you'd like to use please list the dogs name, breed, size, age, and spay/neuter status (if fixed, list when the dog was altered):
*
What skills does your dog know already? (basic obedience, specific task, ect):
*
Is there any behavior personality concerns about the dog that we should be aware of?
*
Please list your veterinarian's contact information:
*
Are there any financial constraints we should be aware of?
*
Please explain what your daily activities consist of:
*
Is there anything else you'd like us to know?
Signature
*
Clear
Today's Date:
*
Month
Month
Day
Year
Apply Now
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