Shelter to Service Eligibility Application

Fields marked with are required.

Are you a veteran?

Applicant's Full Name

Date of Birth

Email Address

Street Address

Address 2

City

State

Zip Code

Phone

How long have you been disabled?

What branch did you serve?

Type of service you are applying for:

Service Dog (PTSD, TBI, Anxiety, Depression, Mobility, etc.)

Military Family Support Dog

Facility Dog

Therapy Dog

Unsure

What is your diagnosed disability/disabilities?

Would you intend on taking a service dog to work with you?

Are you fiscally prepared to provide for the dog's basic needs (i.e. food, supplies, etc.)?

Is your home prepared to welcome a service dog into the environment?

Please list all family members living in your home, including name, relationship, and age.

Please list all pets living in your home, including type, name, age, gender, and if they are spayed/neutered.

If you have pets currently living in your home, we require that they be spayed/neutered and up to date on vaccinations. Please provide the name of your veterinarian's office and the phone number, so that we may verify this information.

How did you hear about this program?

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

What is your ultimate goal (or goal for the recipient) with a possible partnership with a service dog?

What tasks or skills would you like an assistance dog to do for you or the recipient?

Name of the person completing this form:

Shelter to Service Eligibility Application

Shelter to Service

Location

Office Hours

Location

Office Hours