Service Dog Application
When filling out this form, answer questions for the person who will be using the service dog, referred to as APPLICANT, unless otherwise specified.
Applicant's First and Last Name (Who will be using the service dog?) *
Your answer
Applicant's (the person using the service dog) Date Of Birth *
MM
/
DD
/
YYYY
Applicant's Gender *
Height (In Inches) *
Your answer
Weight (In Pounds) *
Your answer
Where are you in the process of obtaining a service dog? *
Please list any questions or readiness information regarding the above question. *
Your answer
List Names And Ages Of All Persons Living In The Home With The Applicant/ Child *
Your answer
Primay Phone Number *
Your answer
Valid E-mail Address - this will be used for all contact with you. If it changes, please email us at merlinskids.servicedogs@gmail.com *
Your answer
Address- must include city and zip code *
Your answer
State *
How or from who did learn about Merlin's KIDS? *
Your answer
Job Description (parents if applying for a child) *
Your answer
Parent/ Guardian Full Name (s) (put n/a if applicant is an adult) *
Your answer
Address Of Guardian/ Caregiver only if different than Applicant's Address, including shared custody arrangements
Your answer
Relationship To Applicant/ Child *
Define The Applicant/ Child's Disability (Be As Specific As You Can) *
Your answer
Cause Of Applicant's/ Child's Disability (Be As Specific As You Can) *
Your answer
Define the Applicant's/ Child's Specific Need For A Service Dog and what tasks you would want the service dog to perform (Be As Specific As You Can) *
Your answer
Do you want the dog to attend school with the child? *
Check All Equipment In Use Currently *
Required
Do You Have Any Other Pets? *
If Yes, List Gender, Type Of Pet, Spay/Neuter, Age, Size, Weight, Breed
Your answer
Do You Have A Fenced In Yard? *
If No, Please Explain Location For Exercise And Bathroom For The Dog
Your answer
Merlin's KIDS can only place dogs as funding is available. Dogs commonly cost between $24,000 to $30,000. Merlin’s Kids subsidizes a portion of the cost so that families are asked to fund raise between $15,000 to $18,000, barring location, cost of travel, and special circumstances. We ask each family to fund raise and/or apply for grants, much of which can be done online. Grants from Merlin's KIDS are prioritized based on a family's active fundraising and full participation in the process. *
If You Already Have Funds raised to donate, or would like to get started on fundraising, please let us know below.
Your answer
Electronic Signature: by typing my name below, I validate that all information is complete and correct. I understand that this is an initial inquiry, to be followed by a full application packet if chosen to move forward in the process. I understand that I will travel to NJ or MO for an evaluation if selected, and that I will be expected to fundraise for Merlin's KIDS, a 501c3 nonprofit.
Your answer
Please write any additional thoughts or questions you have regarding your initial application.
Your answer
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