Service Dog Application

Service Dog Application

Service Dog Application
Applicant's Full Name*
First and last name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant’s Date of Birth*

MonthDayYear
Date
Applicant’s Age*
YesNo
YesNo
Parent/Guardian Name*
Primary Contact Email*
example@example.com
Primary Contact Phone*

Area CodePhone Number

Medical Providers & Health Information
Primary Care Physician Name*
Practice Name*
Provider Phone Number*
Provider Address*
Provider City*
Provider State / Province*
Provider Postal / Zip Code*
Other Medical Providers (Therapists, Specialists)
YesNo
Medical Diagnoses (Primary and Secondary)*
Psychiatric Diagnoses (if applicable)
List all medications the applicant is taking and their purpose*
How does the applicant’s diagnosis affect daily life (including cognitive, physical, or other limitations)?*
Any restrictions or precautions we should know? *
YesNo
What treatments are they receiving?
What, if any, adaptive equipment does the applicant use (speech, hearing, mobility, etc.)?*

Final Confirmation
Name of Person Completing This Form*
How did you hear about Canines for Change?*
I confirm all information provided is true to the best of my knowledge
Signature:*

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Relationship to Applicant*
Date:*

MonthDayYear
Date
Thank you for taking the time to complete this application!

Our team will review it and reach out soon. We appreciate your interest and look forward to connecting with you!

If you’d like more information about the process in the meantime, please visit our website.

Please be sure to check your spam folder for a response about this application. Many of our emails are being sent to spam folders. Thank you.
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