Service Dog Application:
Please read the following terms, then click Next to continue.
Please note: this application is rather extensive. Please allow yourself some extra time to complete it.
Click here to print one out instead
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Today's Date:
Name:
Date of Birth:
What is your Occupation? |
Check this box if unemployed
Contact Info - Part 1 of 2:
Contact Info - Part 2 of 2:
Check this box if you don't have an email
Check this box if you don't have a cell phone
Life and Military Information - Part 1 of 3:
Please choose one option from each question
Are you...?:
Married
|
Single
|
Divorced
|
Separated
|
Widowed
Have you served in the Military?
Yes
|
No
Wars/Conflicts involvement:
Vietnam
Desert Storm/Gulf War
OIF
OEF
Other (please explain)
Branch of Armed Services:
Army
|
Marines
|
Air Force
|
Navy
|
Coast Guard
Current status of Service:
Active Duty
|
Reserve
|
Retired
|
Veteran
How have you changed since returning from the war?
N/A
Life and Military Information - Part 2 of 3:
Almost finished. Just a few more questions
Do you consume alcohol?
Yes
|
No
How often?
Do you live alone?
Yes
|
No
Is there a relative or friend nearby?
Yes
|
No
We will be speaking with your spouse, partner, or adult you live with as to whether the dog would be accepted and incorporated into the household. Please provide name and phone number of person to contact.
Are there children in your home?
No
|
Yes
What ages?
Life and Military Information - Part 3 of 3:
What is a typical day like for you?
How would you incorporate the dog into your day?
How would you exercise your dog?
Have you had dogs previously?
Yes
|
No
What kind of dog?
When?
What, ideally, would you like for your dog to be able to do for you?
Final Questions:
Do you have physical limitations?
What are your opinions of dogs?
In your own words, please describe how you think having a PTSD SERVICE DOG would allow you to become more independent? Less fearful? Less anxious? etc:
How would you respond to the challenges of having a PTSD SERVICE DOG in public places where there might be questions as to its certification and ability to be allowed? What would you say?
Last Question!
In what format would you like to recieve correspondence?
E-Mail
|
Print
That's it! Hit submit to send your application.
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