Program Dog Application

This application will be used to determine if the applicant will benefit from using a Service Dog for their disability given by Mission: Service Dog. All information given will be confidential.

First name

Last name

Birthday

Month

Day

Year

Phone

Address

Is this dog going to be for a minor?

Is the applicant a military veteran? If so please state disability rating:

Tell us about yourself:

Please explain your disability/diagnosis that you are wanting assistance with:

Are you currently using any medical devices or medications for assistance? If so please list what you're using:

How long have you had this diagnosis?

Do you have help with managing a dog in the home?

Are you able to attend local training sessions in Bentonville, AR?:

Please list all of the people in the home with their ages:

What is your experience with dogs?

Are there other animals in the home? If so please list their breeds, age, and spay/neuter status:

Please describe your living arrangements (house, apartment, own/rent, ect)

Is there any financial constraint we should be aware of?

Will you be able to provide the regular cost of vet care for the dog?

Yes

Will you be able to provide the cost of feeding the dog a good quality diet?

Yes

Will you be able to fundraise to cover the cost of your program?

Yes

Please list your veterinarian contact information. If you don't currently have a vet list who you plan to use:

Are there specific dog breeds you would prefer? Please note that we typically use the fab 4 and can not promise any specific dog breed:

Is there anything else you'd like us to know?

Signature

Signature field is empty.

Today's Date:

Month

Day

Year

​Mission: Service Dog

Program Dog Application

Mission:
Service Dog