Assistance Dog Application

Email address *

Full Name *

Your answer

Date of Birth *

YYYY

Address, City, State, Zip *

Your answer

Phone *

Your answer

Email *

Your answer

Occupation *

Your answer

Type of Disability *

Your answer

Date of Diagnosis *

YYYY

Other Medical Concerns *

Your answer

Physicians *

Please include names of all therapists and contact information

Your answer

Therapists (PT, OT, Speech etc) *

Please include names of all therapists and contact information

Your answer

What adaptive equipment/aids do you use? *

Wheelchairs, walker, hearing aids etc

Your answer

Do you drive? *

Yes

If not, how do you plan to attend class? *

Your answer

How did you hear about this program? *

Your answer

What do you plan to gain from admittance to this program? *

Your answer

Option 1

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