Service Dog Application

Fill out this application to enter to receive a life-saving service dog! Deadline to apply is July 1, 2020 for the October 12, 2020 Maggie's Open.

Download Print Version

* 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?

Submit Application