Service Dog Application

Email Address

info@goldenhealers.org

Phone Number

801.738.1050

Our Location

Draper, UT 84020

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Which type of Service Dog are you're applying for: Select one below *

Applicant Name *

First

Last

Parent/Guardian (only required if applicant is under 18)

First

Last

required pets? Living

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Your Occupation *

Housing Situation *

Owner
Renter

Type of Home *

House
Apartment
Town Home
Other

Who else lives in the home? Please list name, relationship to applicant, age *

Are you allowed to have dogs in your home? *

Dog Living Conditions *

Do you have other pets? *

Is your yard shared? *

Is your yard fenced? *

Yes
No
Partially

Do you plan to fence the yard? *

What tasks do you think a service dog could do to make the applicant more independent? (copy) *

Please check box *

I understand

By checking this box, I acknowledge that submission of this application does not guarantee acceptance onto the Golden Healers service dog waiting list. I further understand that this application serves as an initial step to schedule a phone consultation, during which both my suitability for the program and Golden Healers as an appropriate provider will be evaluated.

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Contact Info

PO Box 411 Draper, UT 84020
801.738.1050
info@goldenehealers.org

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