Application Request Form printable pdf download

SUSQUEHANNA SERVICE DOGS

Application Request form

MAIL TO:

SUSQUEHANNA SERVICE DOGS

Client Services Department

1078 Gravel Hill Road, Grantville PA 17028

(717) 599-5920

FULL LEGAL NAME OF APPLICANT:

_____________________________________________________________________________Male____Female____

Last (family) Name

First

Middle Initial

Name of parent or guardian if applicant is a child: _______________________________________________________

MAILING ADDRESS: _____________________________________________________________________________

Street or P.O. box

______________________________________________________________________________________________

City

County

State

Zip Code

PRIMARY E-MAIL: _________________________________________Other Email:

___________________________________________

TELEPHONE: HOME: (

) ___________CELL: (

) _____________WORK (

)____________________

DATE OF BIRTH (of Applicant) : _________ /__________ /_________ ARE YOU A U.S. VETERAN?____yes_____no

month

day

year

OCCUPATION: (OF APPLICANT OR PARENTS):_______________________________________________________

Do you have pets? _______________How many?_____Types (dogs, cats,birds,etc)____________________________

If you have pet dogs, are they spayed or neutered? ___________________________Friendly?____________________

Do you have a good friend or family support system?:______Yes______No

Are both parents willing to accept a service dog in their child's life?______Yes_____No

FOR CHILDREN: Will the dog go to school with the child?_____Yes______No

If YES, send a copy of the most recent IEP and Behavioral Treatment plan along with your application

Do you want the formal application mailed or emailed to you?: ______Email_____U.S. mail

SERVICE DOG INFORMATION

Describe your facility OR disability needs including information about its onset, and prognosis. (Specifically, what are your

limitations, do you have an electric or manual wheelchair, do you use a communication board, hearing aids, etc.?):

Primary Disabilitiy:

Secondary Disability:

Please explain how your disability affects your life and current level of independence:

What type of dog do you feel would meet your needs?:

___Manual Wheelchair ___Power Wheelchair ___Psychiatric___Seizure Response ___Hearing ____Balance

___Austim___Facility___Companion ___In Home Service Dog

OTHER:

What specific services do you feel an assistance dog can provide for you?

COMMENTS:

Additional comments you may wish to share with the partner selection committee:

______I acknowledge that I have read and understand the following:

(The Dogs, The Individuals, The Cost, The Application process and Eligibility requirements)

SIGNATURE: _________________________________________________________ DATE: ____________________

(applicant or parent/guardian if a child)

Application Request Form

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