Service Dog Program Enrollment Form 🐾

Service Dog Program Enrollment Form 🐾

Please fill out this form to apply for our service dog program and get started.
Personal Information
Date of Birth

MonthDayYear
Gender
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please describe why you are applying for a service dog.
Do you have any prior experience with dogs?
Are there specific tasks you need a service dog to assist with?
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
County
List all pets in your home
Do you have the ability to care for and maintain the needs of a service dog
What best describes your living situation?

Other
Do you have a recommendation letter from a doctor
Ethnicity
Race

Other
Income level
Military status
Age
Level of education
Marital status
Employment status
Sexual orientation
Required Documentation
1. Proof of Disability - Letter from Provider or Diagnosis Report

2. DD214 - If you are Active Military or a Veteran

3. Official Work ID - If you are a First Responder

4. Last year's Tax Return

5. Dog Vaccination Record
Upload Required Documents

Please upload any required supporting documents here.
Cancelof
I certify the information provided is true and complete to the best of my knowledge. I understand that submitting an application does not guarantee acceptance into the program.
Signature
Date

MonthDayYear
Date
Should be Empty:

Service Dog Program Enrollment Form 🐾

Personal Information

Required Documentation