Basic Information Form - Service Dog Program
Service Dogs Alabama
Are you completing this form on behalf of your child?
Yes
If you are completing this for your child, what is your child's date of birth?
Name
DOB
Address
City
State
Zip
Email
example@example.com
Are you a student? If so where
Are you employed? If so where
Are you a veteran? If so years of service and branch
Have you discussed having a Service Dog with your family?
Yes
No
Are you prepared or the financial and time commitment that a Service Dog will require?
Yes
No
Do you use any type of adaptive equipment (i.e. wheelchair cane prosthetics hearing aids etc)
HOUSEHOLD INFORMATION
Home Type
Apartment
Condominium
Single Family Home
Other
Do you have a fenced yard?
Yes
No
Are there pets currently in the household
Yes
No
Please list type and breed of each
Do you agree to attend all required trainings
Yes
No
Most of our Service Dogs are Labrador Retrievers, will this breed fit your lifestyle?
Yes
No
What tasks do you think a Service Dog could perform to make you more independent?
Other than specific tasks, how do you think a Service Dog can help you?
Will you be able to feed, exercise, and care for a Service Dog without assistance?
Yes
No
By checking this box, I understand Service Dogs Alabama reserves the right to deny services to any applicant who does not meet the criteria necessary for placement of a Service Dog or who requires services not within the guidelines or capabilities of the organization. It is understood and agreed to that placement of an animal will require the fulfillment of the care and training guidelines of Service Dogs Alabama.
Name
Date
/
Month
/
Day
Year
Date
Submit
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