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.
Salutation:
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
Explanation:
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
Explanation:
A Service Dog will cost $1,500+/year to feed and provide vet care. Can you afford this?* YesNo
Explanation:
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
Explanation:
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
Explanation:
Type of Area you and your Service Dog will visit frequently* : UrbanSuburbanRuralOther
Explanation:
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
Explanation:
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
Explanation:
What other activities were you hoping your Service Dog would perform?
Name of person completing this form and contact information (Phone and email)
Salutation*: