First Responder Application for Service Dog Program

please only complete this application if:
1-you are a first responder with job related PTSD AND
2-you are within a reasonable driving distance to us as this program requires you to come into our facility once a week for a minimum of 6 months

We will contact you within 7-10 business days after submission. PLEASE check your trash/spam folder for our response as our emails sometimes are sent there.

* Indicates required field

Name *

First

Last

Address (including street, city, state) *

Email *

Phone *

Have you been diagnosed with PTSD that is related to your job as a first responder? *

Yes No

Please list your symptoms and any other injuries. *

According to the Americans with Disabilities Act (ADA), a person with a disability is someone who: Has a physical or mental impairment that substantially limits one or more major life activities. Are you considered disabled according to this definition? *

Yes No

Do you currently have a dog? *

Yes No

If yes, please describe *

Please describe your service as a first responder (e.g firefighter, police department, etc) and length of service *

Have you been convicted of a felony? *

Yes No

If yes, please describe *

Submit

please only complete this application if:1-you are a first responder with job related PTSD AND2-you are within a reasonable driving distance to us as this program requires you to come into our facility once a week for a minimum of 6 months

please only complete this application if:
1-you are a first responder with job related PTSD AND
2-you are within a reasonable driving distance to us as this program requires you to come into our facility once a week for a minimum of 6 months