Date of Birth (required)
/   /   
Address (required)

Home Phone: Cell Phone:


Phone Number:

Are you the primary on the Lease or Mortgage? Yes   No
If No, who is:

Your living situation has: Fenced Yard   Enclosed Area   Other
Have you ever had dogs in the family before? Yes   No
If so, do you still have them? Yes   No

Do you have Siblings? Yes   No

Gender: Male   Female

Height: Weight:

How long have you been on current medications?
Have you been hospitalized in the last year? Yes   No

Will dog accompany client to school/work daily? Yes   No

You are responsible for a fundraising requirement of $15,000.
Do you understand? Yes   No

There is a multi-year process before receiving your dog.
Do you understand? Yes   No

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