Training Application Long Form

Section 1: Background

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Email

Phone

Work Phone

Date of Birth

Employer

Spouse's / Significant Other's Name

First

Last

Please give the name and number of a friend or relative we can call if we can't reach you.

Please include their name, relationship to you, and contact phone number.

Please describe your disability.

Is this disability service connected?

Yes
No

What percentage of disability benefits do you receive?

What is your VA disability percentage rating?

Section 2: Lifestyle

Height

Weight

Do you have any physical challenges? Check all that apply.

Activity Level

Low
Medium
High

Do you use a wheelchair?

Yes
No

Please describe other specialized equipment you use (mouthstick, van lift, special keys, etc.)

Please list any additional health problems (e.g. diabetes, epilepsy, cerebral palsy, etc.)

Describe your leisure activities (e.g. TV, visiting friends, team sports, shopping, travel, computers, eating out, etc.)

If you are a student, where do you attend school?

Section 3: Pet History

Have you ever had a dog?

Yes
No

Do you currently have a dog?

Yes
No

What is the dog's name you are wanting to bring through the program?

What is the age of the dog?

What is the breed of the dog?

Please list any other pets that you currently have.

Section 4: Description of Request

Please explain why you would like to have a Service Dog.

Email Address

Phone Number

Our Location

Training Application Long Form

Section 1: Background

Section 2: Lifestyle

Section 3: Pet History

Section 4: Description of Request

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