What Type of Service Dog are You Applying for?

Psychiatric Service DogAutism Assistance DogMobility Service Dog

Recipients Full Name

Parent/Guardian

(only required if applicant is under 18)

Date of Birth

Type of Home

HouseApartmentOther

Do you own or rent?

OwnRent

Do you have a fenced yard?

YesNo

If not, do you plan to fence the yard?

YesNoNA

Who else lives in the home?

Are there currently pets in the home?

YesNo

If Yes, please specify all animals in the home

Can you properly care for the service animal (Pay $25-50/mo to feed, bathe and groom regularly, give daily physical activity)

YesNo

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

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