Assistance Dog Application

Email address *

Full Name *

Date of Birth *

YYYY

Address, City, State, Zip *

Phone *

Email *

Occupation *

Type of Disability *

Date of Diagnosis *

YYYY

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? *

Yes

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? *

Option 1

Clear selection

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