Apply Now - Operation Freedom Paws

Name of Applicant*

First Middle Last

Residence Address*

Street Address Address Line 2 City State ZIP Code

Mailing or PO Box Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Phone*

The phone number above is my*

Home Phone
Cell Phone
Messenger/Pager

Alternate Phone

The phone number above is my

Home Phone
Cell Phone
Messenger/Pager

Email*

Enter Email Confirm Email

Date of Birth*

Are you a veteran?*

Yes
No

Era

Branch

ETS

Are you a first responder?*

Yes
No

First responder type?

Dispatch
EMT
Firefighter
Law Enforcement

How 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 Location

Please 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?*

Yes
No

Age 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*

Yes
No

Other Household Members:

Spouse/Significant Other
Children

Ages of Children in the Household

Are there other animals in the household:*

Yes
No

Please list other animals in the household:

Equipment in Use:

Wheel Chair
Braces
Crutches
Cane
Walker
Prosthetics
Hearing Aid
Other

Type of Wheel Chair

Manual
Power
Both
Electric Scooter

Type 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, Max. file size: 32 MB.

**PLEASE NOTE: You must have a medical letter or prescription signed by a doctor stating you need/require a service animal. If you don't have a medical letter or prescription signed by a doctor, you may save your progress here and return later to finish the application by clicking the "Save and Continue Later" link at the bottom of the form. You must include your medical letter or prescription along with your application for submission when you return.

Name of person completing this form:

First Last

The person completing this form is:*

Self
Parent/Guardian

understand*

* 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.

submitting*

* I am submitting this form in good faith and all information herein is true to the best of my knowledge.

consent

I consent to receiving communications regarding this application, and understand I may withdraw my consent at any time.

Signature*

Phone

This field is for validation purposes and should be left unchanged.

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