*Address Line 1:
Address Line 2:
Birthplace (Town & State):
*Have you ever been convicted of a felony?
If yes, please explain:
*Are you a first responder?
If yes, please specify:
*Are you a member of the US Military?
*Are you active duty?
Are you discharged from the military?
Discharge Date: Type of Discharge:
If discharged please provide a copy of your DD-214 by emailing a copy to Jaclyn DiCarlo at Jaclyn@VetDogs.org or by fax at (631) 930-9075. You can also mail it to America's VetDogs Consumer Services, 371 E. Jericho Tpke., Smithtown, NY 11787
Branch of Service:
*Do you have a visual impairment?
Please list current disabilities, physical limitations, medical conditions or injuries and provide a description of each:
What type of equipment do you routinely use that the Service Dog would have to become accustomed to? (ie. cane, wheelchair, etc.)
*Have you ever had a drug or alcohol abuse problem?
If yes, please detail:
Are you being seen by any of the following specialists?
If any mental health specialists were selected, what is your mental health diagnosis?
*Do you have a legal care giver?
If yes, number of hours a day, week:
SERVICE DOG INFORMATION
Have you previously used a Service Dog?
How many service dogs have you had?
List any schools and dates attended, where you have had Service Dog training:
*Do you have PTSD?
If yes, please answer the following questions:
1) In your own words, describe ways you believe a PTSD Service Dog can assist you in mitigating your PTSD?
2) What tasks do you desire the PTSD Service Dog to perform:
3) How do you deal with anger or frustration?
4) How do you handle conflict?
5) How do you handle confrontation from another person?
6) List all PTSD affected situations and environments that have caused you to have a reaction in the past year:
What are your current living arrangements?
Please list the name, age and relationship of anyone else living in your home?
List any pets/animals that you own inside and outside your home:
What is your current occupation?
Is the entire household committed to the idea of having a Service Dog?
If no, please explain:
Are you able to adequately maintain a service dog financially? (Food, veterinary care and grooming is approximately $75-$100 per month).
If no, how do you plan to maintain a Service Dog financially?
I understand that the Guide Dog Foundation for the Blind®, Inc. and America's VetDogs® - The Veteran's K-9 Corps® (hereinafter referred to as "GDF & AVD") will need further information before my acceptance for training, and that completing this application does not place me nor GDF & AVD under any obligation. This application assists GDF & AVD in assessing my needs and my eligibility for training with a guide or service dog.
I understand that my failure to disclose any medical or personal information that pertains to my ability to work with an Assistance Dog may result in the denial of my application or termination of training.
GDF & AVD does not discriminate against any applicant for admission to our programs based upon race, religion, color, national origin, ancestry, age marital status, gender, or any other factor prohibited under local, state or federal laws.
I hereby declare that the above statements have been truthfully answered to the best of my knowledge.
*Signature (Please type name):
*Date (Enter as MM/DD/YYYY):
CONSENT TO RELEASE - Use your "Arrow" keys to navigate and read the information below. This Consent section of the form must be signed below.
This authorization shall become effective immediately and shall remain in effect for a three-year period from the date it was signed. This is to authorize any physician, hospital, firm, organization or person to furnish to the Guide Dog Foundation for the Blind, Inc. and America's VetDogs - the Veteran's K-9 Corps (hereinafter referred to as "GDF & AVD"), all information, material or opinions that may be requested by GDF & AVD concerning me. GDF & AVD are further authorized to copy any records pertaining to me. I hereby waive any privilege I have to said information to GDF & AVD, and agree to hold GDF & AVD blameless from any claims as a result of the sharing of information related to me.
The Information received by GDF & AVD, will only be used to evaluate my application for a guide or service dog and training in the use thereof.
I understand that any information provided to GDF & AVD will remain confidential.
I understand that my failure to disclose any medical or personal information that pertains to my ability to work with an assistance dog may result in the denial of my application or termination of training.
By clicking “Submit” with my name typed below, I agree to submit this application, which includes the Foundation Code of Conduct and the Consent to Release form, by electronic means and adopt such process with the intent to sign this form.
Please type your full name and this will serve as your signature.
*Signature (Please type name):