Service Dog Application

Fill out this application to enter to receive a life-saving service dog!  

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* indicates mandatory field

Personal Information

Name *
Parents / Guardian *
Address *
Telephone *
Contact Email Address *
Date of Birth *
Gender *
Applicant Photo (person receiving the service dog)

Medical Information

What is your primary disability? *
What are any additional disabilities?
How old were you when your disability was diagnosed? *
What medical devices do you use to assist with your disability? *
Did your medical provider recommend a service dog? *

Additional Information

How many people live in your household? *
Please List name, relationship, age *
What type of housing do you live in? (house, apartment, etc.) *
Do you have a yard? *
Is anyone in your household allergic to animals? *
Does anyone in your household smoke? *
Have you ever owned a dog? *
Have you ever owned a service dog? If yes, explain.
Do you have other dogs/pets? *
If yes, list breed, age and spayed/neutered
Who will assist you in caring for the dog? *
Who will be financially responsible for the expenses associated with owning a dog? (Vaccinations, food, training, etc.?) *
Are you committed to caring for and financially providing for the dog’s care? *
Are you financially able to care and provide for proper care of the dog? *
Describe your relationship with dog/pets in the past
Are you currently in school? *
Will your dog attend school with you? *
What is your district policy on service dogs? *

Essay Questions

What does having a service dog mean to you and your family? *
How do you think a service dog will improve your life? *
What are your future goals and how will your service dog help you achieve them? *

Essay Questions

Any additional information you would like to share?

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