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Assistance Dog Application
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* Required
Email
*
Your email
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?
*
Yes
No
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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