Assistance Dog Application
Email address *
Full Name *
Date of Birth *
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Address, City, State, Zip *
Phone *
Email *
Occupation *
Type of Disability *
Date of Diagnosis *
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/
DD
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Other Medical Concerns *
Physicians *
Please include names of all therapists and contact information
Therapists (PT, OT, Speech etc) *
Please include names of all therapists and contact information
What adaptive equipment/aids do you use? *
Wheelchairs, walker, hearing aids etc
Do you drive? *
If not, how do you plan to attend class? *
How did you hear about this program? *
What do you plan to gain from admittance to this program? *
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