Service Dog Application

Your Name and Address
Salutation* :
Under 21 or incapable of competently caring for a dog?* YesNo If no, please add custodial parent or guardian contact info.
Custodial Information
Salutation :
I approve all communications going to both me and my guardian.
Additional Contact Information
Would you like to add an additional contact? YesNo If yes, please add below.
About You
Do you require a Hearing Alert Dog?* YesNo
Do you require a Seizure Alert Dog?* YesNo
Do you require a Hypoallergenic Dog?* YesNo
Are your living arrangements conducive to caring for a Service Dog?* YesNo
Do you have a support system (family and/or friends) to assist with transitioning to life with our Service Dog and with the responsibilities of owning a dog?* YesNo
A Service Dog will cost $1,500+/year to feed and provide vet care. Can you afford this?* YesNo
Will the applicant (and Parent/Guardian/Caretaker if relevant) be able to attend a 12 day training session in Putnam County, NY? You will be responsible for room and board during this period with some assistance from us.* YesNo
Your Personal Information
Your Birth date :
Your Height : " ' (Feet/Inches)
Your Weight :
Marital Status : SingleMarriedWidowed/WidowerDivorced
Who else lives with you? (People and animals)*
Note: If you have a dog(s) at home, we require that you find another home for your dog(s) prior to receiving our Service Dog. Our Service Dog needs to focus only on you. This is a condition of receiving one of our Service Dogs. If you have a cat(s), you can keep it (them).
Type of Home you live in* : ApartmentHouseOther
Fenced Yard?* : YesNo

Type of Area you live in* : UrbanSuburbanRuralOther
Type of Area you and your Service Dog will visit frequently* : UrbanSuburbanRuralOther
List any Medical Condition(s)* :
Please enter none if no conditions exist.
Disabled?* : YesNo
If Yes, How long have you been disabled?
How does your disability affect your life and current level of independence?:
List the type of activities you want your Service Dog to assist you with
Retrieve and deliver dropped items?* : YesNo
Fetch Items?* : YesNo
Turn lights on and off?* : YesNo
Assist you in dressing?* : YesNo
Assist you in doing the laundry?* : YesNo
Go for help in case of an emergency?* : YesNo
Open doors?* : YesNo

Open drawers?* : YesNo
Press elevator buttons?* : YesNo
Accompany you in crowded situations?* : YesNo
What other activities were you hoping your Service Dog would perform?
Name of person completing this form and contact information (Phone and email)