Appointment Request Form

Owner Trained Service Dog Application

Required for admission into the program
Full Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a qualifying disability? Please explain
When were you diagnosed?
Do you own a dog?

Application Fee

Non-refundable application fee

IF accepted to the program, the fee will be applied to the overall fee.

If not accepted to the program, the fee is non-refundable.

$100.00

Total

$0.00

Credit Card

Should be Empty: