Assistance Dog Support Request Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Please describe your disability or condition that requires an assistance dog.

Type of Support Needed

Do you currently have an assistance dog?

If yes, please provide details about your current assistance dog (name, breed, age, training organization). If no, leave blank.

Please describe your living situation (e.g., house, apartment, with/without yard, household members, other pets).

Have you previously owned or worked with an assistance dog?

Preferred tasks for your assistance dog (select all that apply)

Veterinarian or Support Professional Contact Information (name and phone/email)

Emergency Contact Name and Phone Number

Please provide any additional information or special requirements.