Inquiry Form
The FIRST step for applying for a Service Dog
Date of Inquiry
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Demographics
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Name of Parent/Legal Guardian
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Height: (ft and in)
*
Weight (lbs)
*
How many household members live with you?
*
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Service Details
Are you a Veteran
*
Yes
No
What Service?
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Are you a First Responder?
*
Yes
No
What Type?
*
Firefighter
Law Enforcement Officer
Paramedic
Emergency Medical Technician (EMT)
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Employment
Are you currently employed?
*
Yes
No
Describe your position. (what you do, your work environment, is there physical activity required?
*
Do you volunteer?
*
Yes
No
Where do you volunteer? What do you do?
*
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Disability Information
What is your primary diagnosis?
*
How does your diagnosis impact your mobility?
*
Is your diagnosis due to your military service?
*
Yes
No
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Miscellaneous Information
Do you drive?
*
Yes
No
Do you have a handicap plate or placard?
*
Yes
No
Do you have a yard?
*
Yes
No
Is your yard fenced in?
*
Yes
No
What are the dimensions of the yard?
*
Where will you adequately be exercising your dog?
*
Do you have pets?
*
Yes
No
How many, type, breed, age and temperament?
*
Would you like to be added to our Monthly Newsletter?
*
Yes, sign me up!
No thank you.
By signing below, I am attesting that all information I have provided is true to the best of my knowledge.
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