KSDS Service Dog Application Request
Average wait: 2 years from date of application acceptance
KSDS Assistance Dogs, Inc.
120 W 7th St.
Washington, KS 66968
785-325-2256
Fax: 785-325-2258
snutsch@ksds.org
Applicant Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Work Phone
Mobile Phone
E-mail
*
Applicant Age
*
Must be 14 years or older
Parent Name (if applicant is a minor)
Primary Disability
*
Duration of Disability
*
Cause of Disability
*
Effects of Disability
*
If the applicant uses a mobility aid, describe it.
If the applicant has hearing or vision loss, describe it.
Additional Information
Submit
Should be Empty: