Service Dog Sponsorship Application

Service Dog Sponsorship Application

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Name:

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Pronouns you identify with: (she/her, he/him, they/them/theirs)
Home Phone Number:
Format: (000) 000-0000.
Mobile Phone Number:
Format: (000) 000-0000.
E-mail Address:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Other:
Are you a veteran or first responder
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?
Name of current employer (if none, type none)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's phone number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently a student? (If yes, where?)
Emergency contacts
Emergency Contact 1
Name:

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship: (Spouse, Mother, Son, Father, Daughter, friend, etc.)
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2
Name:

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship: (Spouse, Mother, Son, Father, Daughter, friend, etc.)
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
More about you
What is your disability/disabilities:
How long have you been disabled?
Is your disability service-related?
You Are:
You live in a:
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?
Clients are expected to meet on an annual basis for evaluation, do you agree to do this?
Upload Photo:

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Autobiography:

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Upload Tax Return or Financial Statement:

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Is there anything else that you'd like to share with us?
Should be Empty:

Service Dog Sponsorship Application

Emergency contacts

Emergency Contact 1

Emergency Contact 2

More about you

Pets in your home/Service Dog care