Therapy/Service Dog Application

Please complete this form so that we can get to know you better and determine what type of dog would be the best fit for your needs. All information will be kept confidential.

First name

Last name

Email address

Phone number

Date of birth

Month

Day

Year

Are you a military veteran?

Yes, I am a veteran

No, I am not a veteran

Home address

Country/Region

Address

City

Zip / Postal code

Type of assistance dog needed

Please describe your specific needs and how a therapy or service dog would assist you

Have you previously owned a dog?

Yes, currently own a dog

Yes, previously owned a dog

No, never owned a dog

Have you previously owned a service or therapy dog?

Yes, currently have a service/therapy dog

Yes, previously had a service/therapy dog

No, never had a service/therapy dog

Describe your experience with dogs

Are you able to commit to daily exercise and training with the dog?

Yes, I can provide daily exercise and training

Yes, with assistance from others

Limited ability due to my condition

No, I would need significant help

Do you plan to work with a professional trainer?

Yes, I already have a trainer in mind

Yes, I would like help finding the right trainer

No, I do not plan to work with a trainer

I'm unsure and would like more information

Additional information