EmailMe Form - Lead Dog Service Dogs

Appilcant Name *

First Last

Gender

Male

Female

Date of Birth

Are you a U.S. Veteran?

Name of parent or guardian if applicant is a child

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Occupation (of Applicant or Parents)

Do you have pets? *

Yes

No

Type (dogs, cats, birds, reptiles, etc.)

If you have pet dogs, are they spayed or neutered?

Yes

No

Are your pets friendly?

Yes

No

Do you have a good family support system? *

Yes

No

Are both parents willing to accept a service dog in their child's life? *

Yes

No

Will the dog be going to schooler work with the handler? *

Yes

No

How would you like to receive the formal application? *

Mail

Email

Please describe your disability needs, or facility needs, including information about its onset, and prognosis. (Specifically, what are your limitations, do you have an electric or manual wheelchair, do you use a communication board, hearing aids, etc.?)

Primary disability

Secondary disabilty

Please explain briefly how your disability affects your life and current level of independence.

What type of Dog do you feel would meet your needs?

What specific needs or services do you feel a Service Dog can provide for you?

Additional comments you may wish to share with us: