Assistance Dog Application
Email address *
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address, City, State, Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Occupation *
Your answer
Type of Disability *
Your answer
Date of Diagnosis *
MM
/
DD
/
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? *
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
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