Service Dog Sponsorship Application
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Name:
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
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Month
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Day
Please select a year
2025
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Year
Pronouns you identify with: (she/her, he/him, they/them/theirs)
Home Phone Number:
Mobile Phone Number:
*
E-mail Address:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Website
Newspaper Ad
Facebook
Other (please specify)
Other:
Are you a veteran or first responder
Please Select
Yes
No
Applicants are expected to contribute a portion of the cost of a Service Dog. Do you acknowledge and accept your responsibility of $4000 due at the start of the program and $4000 due in agreed upon increments over the course of 16 months?
Please Select
Yes
No
Name of current employer (if none, type none)
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer's phone number
Please enter a valid phone number.
Are you currently a student? (If yes, where?)
Emergency contacts
Emergency Contact 1
Name:
*
First Name
Last Name
Phone Number
*
Relationship: (Spouse, Mother, Son, Father, Daughter, friend, etc.)
Years Known:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 2
Name:
*
First Name
Last Name
Phone Number
*
Relationship: (Spouse, Mother, Son, Father, Daughter, friend, etc.)
Years Known:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
More about you
What is your disability/disabilities:
*
How long have you been disabled?
Is your disability service-related?
Please Select
Yes
No
You Are:
Please Select
Single
Married
Divorced
Separated
Widowed
You live in a:
Please Select
House
Apartment
Condominium
Other
How long have you lived there?
Please list the names, relationship and age of everyone you live with:
Do you anticipate a move or lifestyle change within the next year? Please explain:
Do you suffer from any of the following? Check all that apply
Other:
Do you use any of the following? Check all that apply
Other:
Do you require attendant care? Yes/No If yes, please describe:
Describe your activity level (low, moderate, high) and explain:
Are you able to walk? Yes/No If yes, how far (or how long) can you walk?
Do you have any problems communicating verbally? Yes/No If yes, please describe:
Do you have any vision or hearing problems? Yes/No If yes, please describe:
Do you now have or have you ever had a substance abuse problem? Explain:
Please describe your home life and all the activities you enjoy doing (hobbies, recreation, social activities, etc.)
Please describe places you frequent and what obstacles you face there? (Example: Grocery store, I feel panicked when someone is standing directly behind me)
Please describe all the means of transportation you use:
Are you able to transfer independently? Yes/No If no, describe how you transfer
Pets in your home/Service Dog care
Please list all the pets that live with you and include their name, species/breed, sex, age and their spay/neuter status:
Please include the contact information for your veterinarian including their phone number:
Please describe your knowledge of dog behavior:
Please describe your knowledge of dog care:
Please describe how you will deal with your service dog when s/he sheds, needs veterinary care and food. Can you fulfill these obligations in both time and resources?
What characteristics do you like in a dog?
What characteristics do you NOT like in a dog?
In order of importance, please list the task(s) you would like your dog to perform for you:
Please describe the place you live and your access to a yard or how you plan to exercise your dog:
Will you commit yourself to meeting the physical and mental needs of a working dog?
Please Select
Yes
No
Clients are expected to meet on an annual basis for evaluation, do you agree to do this?
Please Select
Yes
No
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