SSDS Seniors for Seniors Program Interest
Please fill out this form if you or someone you know would be interested in a senior dogs for seniors program in Northern NJ.
Name
*
First Name
Last Name
Email
*
example@example.com
Residence of Service Recipient
House
Apartment
Assisted Living
Skilled Nursing Facility
Retirement Home
Memory Care
Unsure
None of the above
Does this person have major health concerns that require constant medical aid/assistance?
Yes
No
Town (Northern NJ)
*
Does this person have a known allergy to pets
Yes
No
Submit
Should be Empty: