Service Dog Application Form Please fill out our application form below to be considered for a service dog. You will need a letter from your doctor recommending a service dog before completing the application process. **Please note that while we do our best to serve everyone in need, not all applications will be accepted into the program.** If you prefer, you can download and print out the PDF version of the form instead of completing the online form below. Please fill it out and mail it, along with your doctor's letter to: Operation Freedom Paws 777 First Street PMB 515 Gilroy, CA 95020Name of Applicant* First Middle Last Residence Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing or PO Box Address (if different from above) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*The phone number above is my*Home PhoneCell PhoneMessenger/PagerAlternate PhoneThe phone number above is myHome PhoneCell PhoneMessenger/PagerEmail* Enter Email Confirm Email Date of Birth* Date Format: MM slash DD slash YYYY Are you a veteran?*YesNoEraBranchETSHow did you hear about the Operation Freedoms Paws Service Dog program? Operation Freedoms Paws Web Page Referral Veteran Affairs Dream Power Horsemanship Other Referred by (name)VA LocationPlease describe "Other"Type of dog applying for:* Mobility Assistance PTS TBI Seizure Hearing Assistance Allergy Alert Other Please describe "Other"What is your disability?*How long have you been disabled?*How long have you been looking for a service dog?*What tasks or skills would you like an assistance dog to do for you or the recipient?*Please describe how your disability affects your life and your current level of independence:*What is your ultimate goal (or your goal for the recipient) with a possible partnership with an assistance Dog.*Do you have your own dog that you would like to train as a Service Dog?*YesNoAge of Dog (in years)Please enter a number from 0 to 20.Types of Assistance Skills Desired:* Pick up/Retrieve Items Open/Close Cabinets Safety Provide Bracing to Stand, Walk, Sit, Balance Open/Close Doors Emotional Stability Depression Help in Emergencies Other Please describe "Other"Home Environment:* Apartment Home Shared Housing Assisted Living Homeless We're sorry, but you cannot apply if you do not currently have a stable home. Once your housing situation becomes stable, please come back and finish filling out the application. The "Save and Continue Later" link at the bottom of the screen will remain valid for 30 days.Fenced Yard*YesNoOther Household Members: Spouse/Significant Other Children Ages of Children in the HouseholdAre there other animals in the household:*YesNoPlease list other animals in the household:Equipment in Use: Wheel Chair Braces Crutches Cane Walker Prosthetics Hearing Aid Other Type of Wheel ChairManualPowerBothElectric ScooterType of Braces Leg Arm Wrist Please list type(s) of prosthetics:Please describe other equipment in use:Doctor's Letter or Prescription*Accepted file types: pdf, rtf, doc, docx, txt, jpg.You must have a medical letter or prescription signed by a Doctor stating you need/require a service animal before submitting your application. (If you do not yet have a medical letter or prescription, you may save your progress and return later to finish the application by clicking the "Save and Continue Later" link at the bottom of the form.)Name of person completing this form: First Last The person completing this form is:*SelfParent/Guardian* * I understand that all applicants must become a client of Operation Freedoms Paws to receive a “service dog”. While we do our best to serve everyone in need, please note that not all applications will be accepted into our program. * * I am submitting this form in good faith and all information herein is true to the best of my knowledge. I consent to receiving communications regarding this application, and understand I may withdraw my consent at any time. Signature*PhoneThis field is for validation purposes and should be left unchanged.
