W.D.F.V. No Veteran Left Behind Application
Email address *
First Name *
Your answer
Last Name *
Your answer
Do you have a dog you want to train as your service dog? (Dog's Name Only) *
If you do not have a current dog that you would like to train, please select the first option (/)
Required
Your potential service dog's information *
Please provide your dogs breed, age, and gender.
Your answer
Is the dog spayed/neutered *
It is Working Dogs For Vets policy that all dogs will be fixed before the dog will receive certification.
Does your dog have a microchip, if so what is the number? *
Your dog will be required to have a Micro Chip and the chip number will need to reported to Head Quarters
Your answer
Your Address *
If you move you MUST notify W.D.F.V. immediately as to your new address.
Your answer
City *
Your answer
State *
Zip
Your answer
Home phone *
If you change your phone number you MUST notify W.D.F.V. immediately as to your new phone number.
Your answer
Cell phone
Your answer
Emergency Contact *
Who can we reach out to in an event of an emergency and what is their relationship to you?
Your answer
Emergency Contact Phone Number *
Your answer
Your Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Are you a U.S. Veteran? *
Do you have a military affiliation? *
What branch?
Your answer
Are you Active or Retired?
Your answer
Is someone in your family in the military?
If yes, Who?
Your answer
Information about your home, what type is it? *
Do you rent or own your home? *
Do you have a fenced in yard? *
If no fenced in yard, do you have an area in mind to exercise your dog? *
Who else lives in your home? *
Please provide: Names, relationships, and ages of all in house hold below:
Your answer
Does everyone in your household agree about you getting a service dog? *
Do you have any other animals in your home? *
If yes please list below and include: dog, cat, other, and if they are spayed/neutered.
Your answer
Are you employed? *
Occupation?
Please include: occupation name, how many hours daily/weekly do you work, and normal work activities?
Your answer
Do you attend school? *
School Information:
Please provide: how many hours daily/weekly and normal activities at school.
Your answer
Please describe your disability or facility needs, including information about its onset and prognosis. Specifically, what are your limitations? *
Your answer
Have you ever owned a dog before? *
When was the last time you owned a dog?
Your answer
What type of service dog would meet your needs?
Please explain why you want a service dog *
Your answer
What needs or services do you feel a service dog will provide for you? *
Your answer
Are you able to train your dog? *
How many hours a day will your service dog be alone? *
Hours per day
Your answer
How much do you think it costs for the care of a service dog? *
$ Monthly/ $ Yearly
Your answer
Do you feel that you can afford to pay these costs? *
Do you currently have a veterinarian? *
Is there anything else you would like to add to your application?
Your answer
Do you agree to the following…. *
That there is a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8-10 years? Yes, or No- if no please explain
Your answer
You agree to: attend to daily training and care, to attend training classes with your dog, to provide your dog with appreciation and respect by making time to bond with your service dog each day, to provide daily exercise and play, to practice the dogs skills and obedience regularly, to maintain the dog’s proper behavior in public and at home, to keep the dog well groomed and well cared for, to arrange for prompt clean up of dog’s waste, to practice preventative health care for the dog, and to obtain annual health checks and vaccinations for the dog. *
You understand and agree that you must: carry proper identification and be aware of all applicable laws pertaining to assistance dogs, to abide by all leash and license laws, that a W.D.F.V. dog spends most of their time with their partner at home and at work, at school, social events, and vacations if he/she is certified for public access, that no W.D.F.V. dog will be in a yard or kennel for long periods of time, that a W.D.F.V. dog is not a family pet - he/she has a specific function in their handler's life, that W.D.F.V. dogs cannot be allowed off leash except in a secure area, and that exercise and elimination must be done on leash, or in a fenced yard, or dog run. *
Program supplies: Enrollment certificate, ID Badges, and Embroidered Patch's are property of W.D.F.V. If at any time you are not following program rules, regulations, or agreement's, W.D.F.V. and or W.D.F.V. Volunteers have the right to remove these from you and you will be terminated from our program. You agree that a service dog is a lifelong commitment, and that as your needs change your service dog may need additional training. You agree that the service dog is never to be given away, or sold! *
If a W.D.F.V. volunteer is finding a dog for you, they may need to share with the shelter some information from this application in order to do so. We need to verify that you understand our policy and procedure in order for us to assist you in finding a dog suitable to your needs.
I agree that by participating in the No Veteran Left Behind Program, when I present my Id, certification, or when my dog is wearing a W.D.F.V. Logo, that I am representing W.D.F.V. and that both myself and my dog are ambassadors for Working Dogs For Vets, as well as the entire assistance dog industry and I will be expected to maintain my dogs appearance and manners, as well as my handling skills. When taking my dog into public, my dog will be well groomed. My dog will be properly house trained, but in the event of an accident I will arrange for prompt cleanup of my dogs waste. My dog should not, growl or show any aggression. Will abide by all leash and licence laws. There will be no jumping up or causing distractions. If someone asks about my dog I will be courteous. In the event that I am asked to leave or denied access, I agree to remain calm show my I.D. and the law on the back of the card, if necessary I will contact proper authorities, leaving the premises immediately. Making sure to get a copy of the report and contact W.D.F.V. so that we can assist you in filing a complaint with the A.D.A. I understand this is not a replacement for therapy or doctor visits, I agree to continue to take my medications and follow all doctor/therapist’s orders. I agree to make the transaction of my service dog into my community as easy as possible. This is done by handing out brochures and informing the places that I usually attend about my new service dog. I agree to make all appointments with my volunteer trainer and to listen to all instructions. In the event that I need to cancel with my volunteer, I must be courteous and give proper notice and reschedule. I agree while training my dog, that the dog will not be harmed as I will remain patient, remembering that tomorrow is another day, I will put my dog up if I am angry or annoyed. I agree that my dog will be spayed or neutered, and shots & vet records will be kept up to date. I agree that if I feel I am capable of hurting the dog I will contact W.D.F.V. & assist in finding the dog a new home. I agree that no matter how friendly my dog is that I will always watch him/her around children, adults, & other animals. Always remembering that my dog is still a dog. I agree to hold harmless Working Dogs for Vets, & all volunteers as a whole or individual from any mental/ physical injury to myself and others. Including property damage, weather it be people, property, or any other type of damage caused by myself or the dog. As your doctor recommended for you to have a service dog, we will need to have a copy of your recommendation on file. That if I am not mentally or physically capable of participating in the program, or if a Doctor/therapist recommends I do not participate in the program I will quit effective immediately. I hereby swear that all information given to W.D.F.V. is true and accurate. I hereby swear to help any veterans in need when able to do so without questioning how or why the circumstances require my help. As my knowledge increases in training dogs, I agree to share that knowledge with other veterans in need of a service dog. I agree that if I decide to give up the ownership of the dog at any time or for any reason W.D.F.V. must be consulted. I am prohibited from giving away or selling a service dog to any other party unless specifically consented to do so by W.D.F.V. W.D.F.V. requests voluntary agreement to use photographs, video’s or testimonials to utilize in marketing materials, fundraising efforts, & or public relations. As I pledged an oath as I went into the military, I now swear a new pledge & a new oath that No Veteran is Left Behind. I am now obligated to follow all agreement rules & regulations. Link to view https://docs.google.com/document/d/1zAMKy7XRRymgPFYyrCRm6srfIQ_VgydaxK9H951cUYg/edit?usp=sharing *
By signing below I hereby acknowledge that I have read over the application and answered all answers truthfully to the best of my ability. I understand that Working dogs for vets reserves the right to deny service to an applicant for any reason including but not limited to failure to meet the established criteria for receiving a service dog or right to remove a program service dog from a home at any time for mistreatment/neglect or inappropriate match. I do hereby agree to hold free from any and all liability Working dogs for vets/ Partners its members and officers. I declare myself to be physically sound to participate with working dogs for vets. My family, members of my household and myself wave the rights and claims for damages & injuries, which may come from my connection & participation with working dogs for vets. All applicants will be considered regardless of race, sex, religion, creed, sexual orientation and ethnic origin. *
Please type your full name:
Your answer
We will need a doctor's recommendation letter filled out. Do you agree to bring this letter to your doctor? *
Please copy this link into browser, Print and take to your doctor for recommendation. https://docs.google.com/document/d/1oyM1ZoodPVkvjbp6p4Z6fp8xO5sKT2HRR7fJyYc6Oy8/edit
This online form needs to be printed out, signed, and returned by mail to: Working Dogs For Vets, No Veteran Left Behind Program, 2781 Hwy 43 N, Lawrenceburg TN 38464 *
I agree to print, sign, and send.
A copy of your responses will be emailed to the address you provided.
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