K9 Service Dog Application - K9S FOR VETERANS

K9s For Veterans, NFP Service Dog Application

K9s For Veterans, NFP Service Dog Application Thank you for your interest in K9s For Veterans, NFP. K9s for Veterans, NFP is dedicated to helping veterans suffering from Post-Traumatic Stress Disorder (PTSD) or TBI by providing them with service dogs. We’re honored to help the men and women who so bravely served our country. These dogs dramatically improve their quality of life. While there are many service dog organizations, K9s for Veterans is proud to say that we offer some unique benefits to veterans.

In order to qualify for our program please provide the following information:
1. Completed Application

2. Upload a current photo at the end of the application (a full length photo is required, head shots not acceptable) or email a current photo to k9sforveterans@aol.com

3. Upload an official signed letter from your medical doctor, psychiatrist, psychologist or other licensed mental health care professional indicating a service animal would beneficial for you. (This letter must be current. Letters more than 45-days before the date of your application will not be accepted (you may also email to k9sforveterans@aol.com

4.DD-214. If you have multiple periods of services and have separate DD-214 we must have all pertaining to service

5. Name and Phone of psychiatrist, psychologist or other licensed mental health care professional should any questions arise at the application process to end of program.

Once the above is completed your application will be reviewed and a member from the Board of Review Committee will contact you.

I have read the above and agree to the terms and conditions set forth
* Indicates required field

Digital Signature (First & Last Name)*

Today's Date*

Date

First Name*

Last Name*

Address*

Apt or Building #

City*

State*

Zip Code*

Country

Cell Number*

Home Phone (ex. 555-555-5555)

Email*

Marital status:*

Gender*

Date of Birth*

Date

Age*

Emergency Contact Name*

Relationship*

Phone Number*

Do you have a valid drivers license*

If no, do you take public transportation (bus, tax, or does someone else drive you or your vehicle? explain

Are you currently involved in any litigation of any kind?*

If yes, please explain:

How many people live in your household?*

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Is anyone listed above your caretaker?*

If yes, how often are they with you?

Is anyone living in the household allergic to dogs?*

Name

Age

Relationship

Name

Age

Relationship

Does anyone that visits your home frequently, allergic to dogs?*

If yes please explain:

Is anyone living in the household physically or mentally disabled?*

If yes, explain how they are disable and what their limitations are:

Do you have any pets?*

YesNo

If yes, how many cats, dogs, or other?

Veterinarian/Animal Clinic Name:

Phone Number

Type of pet

Age

Name

Type of pet

Age

Name

Type of pet

Age

Name

Type of pet

Age

Name

Are they friendly with other dogs?

If no, explain how you would handle your current pet and the service animal:

If you become hospitalized, who would take care of these animals:*

Are you physically able to feed, walk and groom the service animal?*

YesNo

If no, please explain:

Are you able to clearly verbalize commands to the service animal?*

YesNo

If no, please explain:

Type of home:*

Own*

OwnRent

If an apartment or renting a home, are pets allowed?*

If yes please explain:

If a mobile home, is your residence in a mobile home park?

Is there a fenced yard?*

NoYes

Is there a lot of traffic or major road near your residence?*

Are their businesses or stores/restaurants near your residence?*

YesNo

Is there a lot of noise near your residence?*

YesNo

Do you currently work/school outside of your home?*

YesNo

If yes, will your service animal accompany you to work/school?*

YesNo

If yes, provide a letter from your school/work acknowledging that your service dog will be accompanying you to class/work and would not be put in harm’s way.

Branch of Service:*

Entered Active Service Date (MM/DD/YY)*

Discharge Date (MM/DD/YY)*

Entered Active Service MOS:*

Discharge MOS:*

Date officially diagnosed with PTSD and/or TBI (MM/DD/YY)*

Name of the Medical Center/Physician that determine diagnosis:*

Line 1

Line 2

City

State

Zip Code

Country

Phone Number

Name of Doctor:

What is your primary diagnosis

Do you have a secondary diagnosis?

YesNo

Describe:

Name of the Medical Center/Physician that determine diagnosis:*

Line 1

Line 2

City

State

Zip Code

Country

Phone Number

Name of Doctor

Do you have any history of the following:

Violence to others?*

YesNo

If yes, please explain:

Harming Yourself?*

YesNo

If yes, please explain:

Harming Animals?*

YesNo

If yes, please explain:

Substance abuse alcohol/drugs*

YesNo

If yes, please explain:

Upload current photo of yourself (a full length photo is required, head shots not acceptable)

That K9s For Veterans, NFP has your authority and permission to contact any personal or medical professional reference. (If you agree type your initials here)*

At any time a representative of K9s For Veterans, NFP may remove the provided service animal from my possession if any animal cruelty of any type may be suspected or if at any time the Veteran is incarcerated. (If you agree type your initials here)*

The Veteran will not give up or abandon the provided service animal. (If you agree type your initials here)*

I also understand that I am required to attend 6 hours a month training classes at the K9s For Veterans, NFP training center and it is my financial responsibility to provide my own transportation and housing to and from the training center facility. Public transportation is not acceptable until the service dog has completed certification. (If you agree type your initials here)*

All information in this application is true and accurate and that an incomplete application will not be reviewed until it is complete. (If you agree type your initials here)*

Applicant Digital Signature:*

Date*