Main Line Deputy Dog APPLICATION

Main Line Deputy Dog APPLICATION
Today's Date

MonthDayYear
Date
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
E-mail*
Cell phone*

Area CodePhone Number
Home or Office phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your diagnosis: physical challenge/ psychiatric concern . How long have you been having these?*
How did your situation/circum-stances develop?*
What tasks would you like your dog to be able to perform for you?
If you have a dog, dog's name/age**
Breed
Dog license
Veterinarian / phone#
Any additional info
We also require the completion of a Physician's Questionnaire and

a Veterinarian's Questionnaire**, you will receive these forms at

your initial interview.

** A dog you have may or may not be suited for service dog work

Main Line Deputy Dog is an equal opportunity organization and does not unlawfully discriminate against volunteers, students, board members, associates, participants, or applicants for work on the basis of an individual’s race, color, religion, creed, sex, national origin, age, disability, marital status, veteran status or any other status protected by applicable law. This policy applies to all terms, conditions and privileges of work participation, including recruitment, placement, assignment, compensation, promotion, discipline and termination.

Whenever possible, Main Line Deputy Dog makes reasonable accommodations for qualified individuals with disabilities to the extent required by law. Associates who would like to request a reasonable accommodation should contact the Executive Director.

Violations of this policy will not be tolerated.
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