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Our Mission
Programs
Veteran Program
Advocacy and Speaking Engagements
Canine Programs
Donate
VA Resources
Service Dog Teams
Contact Us
Donate Today
First Name:
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Last Name:
Phone Number:
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Email Address:
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Street Address
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City
State
ZIP / Postal Code
Best time to contact you:
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Morning
Evening
Other
If other, please let us know the best time to contact you.
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Are there other pets in the household?
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Yes
No
If yes, please list animal and age:
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Are there children in the household?
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Yes
No
If so, please list the ages:
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What is your current living situation?
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What type of service are you looking for?
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What is your primary disability and your combined disability rating from the VA?
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Have you applied for other service dog programs? If so, please list:
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Are you looking for mentorship in the process of obtaining a service dog?
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Please describe how your disability affects your life and your current level of independence:
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In just a few sentences, what is your ultimate goal with a service dog?
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Have you had professional dog training before?
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Yes
No
Was it one-on-one or with a group class?
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Have you ever been to a Board and Train facility?
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Yes
No
If so, please list:
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What were the results of the above listed professional training and/or board and train programs?
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Describe your relationship with your dog now:
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Dog Information:
Dog Name:
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Breed:
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Age:
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Date of most recent vaccines:
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Veterinary Office
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Phone Number:
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Street Address:
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City:
State:
ZIP Code:
Emergency Contact:
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Phone Number:
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Is your dog currently taking any medication or under any medical care/supervision?
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Has your dog ever bitten anyone?
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Yes
No
Please describe:
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Is your dog currently licensed in your county of residence?
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Yes
No
Please describe your dog's current behavior, including any behavioral problems or areas of concern:
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