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K9s For Veterans, NFP Service Dog Application
K9s For Veterans, NFP Service Dog Application Thank you for your interest in K9s For Veterans, NFP. K9s for Veterans, NFP is dedicated to helping veterans suffering from Post-Traumatic Stress Disorder (PTSD) or TBI by providing them with service dogs. We’re honored to help the men and women who so bravely served our country. These dogs dramatically improve their quality of life. While there are many service dog organizations, K9s for Veterans is proud to say that we offer some unique benefits to veterans.
In order to qualify for our program please provide the following information:
Completed Application
Upload a current photo at the end of the application (a full length photo is required, head shots not acceptable)
or email a current photo to
k9sforveterans@aol.com
Upload an official signed letter from your medical doctor, psychiatrist, psychologist or other licensed mental health care professional indicating a service animal would beneficial for you. (This letter must be current. Letters more than 45-days before the date of your application will not be accepted
(you may also email to
k9sforveterans@aol.com
DD-214. If you have multiple periods of services and have separate DD-214 we must have all pertaining to service
Name and Phone of psychiatrist, psychologist or other licensed mental health care professional should any questions arise at the application process to end of program.
Once the above is completed your application will be reviewed and a member from the Board of Review Committee will contact you.
I have read the above and agree to the terms and conditions set forth
*
Indicates required field
Digital Signature (First & Last Name)
*
Date (mm/dd/yy)
*
Section 1 — Personal Information
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Cell Number
*
Home Phone (ex. 555-555-5555)
*
555-555-5555
Email
*
Choose Any
*
Single
Married
Separated
Divorced
Widowed
Domestic Partnership
Gender
*
Male
Female
Date of Birth (mm/dd/yy)
*
Age
*
Emergency Contact Name
*
Relationship
*
Phone Number
*
Do you have a valid drivers license
*
Yes
No
If no, do you take public transportation (bus, tax, or does someone else drive you or your vehicle? explain
*
Are you currently involved in any litigation of any kind?
*
No
Yes
If yes, please explain:
*
Personal References
Name
*
Phone Number
*
Name
*
Phone Number
*
Name
*
Phone Number
*
SECTION 2 — HouseHold Information
How many people live in your household?
*
Name
*
Age
*
Relationship
*
Name
*
Age
*
Relationship
*
Name
*
Age
*
Relationship
*
Name
*
Age
*
Relationship
*
Is anyone listed above your caretaker?
*
No
Yes
If yes, how often are they with you?
*
Is anyone living in the household allergic to dogs?
*
No
Yes
If yes please indicate:
Name
*
Age
*
Relationship
*
Name
*
Age
*
Relationship
*
Does anyone that visits your home frequently, allergic to dogs?
*
No
Yes
If yes please explain:
*
Is anyone living in the household physically or mentally disabled?
*
No
Yes
If yes, explain how they are disable and what their limitations are:
*
Do you have any pets?
*
Yes
No
If yes, how many cats, dogs, or other?
*
Veterinarian/Animal Clinic Name:
*
Phone Number
*
Type of pet
*
Age
*
Name
*
Type of pet
*
Age
*
Name
*
Type of pet
*
Age
*
Name
*
Type of pet
*
Age
*
Name
*
Are they friendly with other dogs?
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Yes
No
If no, explain how you would handle your current pet and the service animal:
*
If you become hospitalized, who would take care of these animals:
*
Are you physically able to feed, walk and groom the service animal?
*
Yes
No
If no, please explain:
*
Are you able to clearly verbalize commands to the service animal?
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Yes
No
If no, please explain:
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Type of home:
*
House
Apartment
Mobile Home
Other
Do you own or rent your home?
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Own
Rent
If an apartment or renting a home, are pets allowed?
*
Yes
No
If a mobile home, is your residence in a mobile home park?
*
Yes
No
Is there a pet size restriction?
*
No
Yes
If yes please explain:
*
If a home, do you have a fence around your yard?
*
Yes
No
Is there a lot of traffic or major road near your residence?
*
Yes
No
Are their businesses or stores/restaurants near your residence?
*
Yes
No
Is there a lot of noise near your residence?
*
Yes
No
Neighborhood:
*
Suburbs
City
Country
Farm
SECTION 3 — Employment/EDucation
Do you currently work outside of your home?
*
Yes
No
If yes, will your service animal accompany you to work?
*
Yes
No
If yes, please attach a letter from your employer acknowledging that your service dog will be accompanying you to work and would not be put in harm’s way.
*
Max file size: 20MB
If yes, provide a letter from your school acknowledging that your service dog will be accompanying you to class and would not be put in harm’s way.
Do you currently attend a school/college/trade school?
*
Yes
No
If yes, will your service animal accompany you to
*
Yes
No
If yes, provide a letter from your school acknowledging that your service dog will be accompanying you to class and would not be put in harm’s way.
*
Max file size: 20MB
SECTION 4 — Military Service
Branch of Service:
*
Entered Active Service Date (MM/DD/YY)
*
Discharge Date (MM/DD/YY)
*
Entered Active Service MOS:
*
Discharge MOS:
*
Section 5 – Medical Information
Date officially diagnosed with PTSD and/or TBI (MM/DD/YY)
*
Name of the Medical Center/Physician that determine diagnosis:
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Name of Doctor:
*
What is your primary diagnosis
*
Do you have a secondary diagnosis?
*
Yes
No
Describe:
*
Name of the Medical Center/Physician that determine diagnosis:
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Name of Doctor
*
Do you have any history of the following:
Violence to others?
*
Yes
No
If yes, please explain:
*
Harming yourself?
*
Yes
No
If yes, please explain:
*
Harming an animal?
*
Yes
No
If yes, please explain:
*
Substance Abuse alcohol/drugs
*
Yes
No
If yes, please explain:
*
Upload current photo of yourself (a full length photo is required, head shots not acceptable)
*
Max file size: 20MB
By signing this digital application, you agree to the following: (initial after each statement)
That K9s For Veterans, NFP has your authority and permission to contact any personal or medical professional reference. (If you agree type your initials here)
*
If you agree type your initials here
At any time a representative of K9s For Veterans, NFP may remove the provided service animal from my possession if any animal cruelty of any type may be suspected or if at any time the Veteran is incarcerated. (If you agree type your initials here)
*
If you agree type your initials here
The Veteran will not give up or abandon the provided service animal. (If you agree type your initials here)
*
If you agree type your initials here
I also understand that I am required to attend 6 hours a month training classes at the K9s For Veterans, NFP training center and it is my financial responsibility to provide my own transportation and housing to and from the training center facility. Public transportation is not acceptable until the service dog has completed certification. (If you agree type your initials here)
*
(initials here)
All information in this application is true and accurate and that an incomplete application will not be reviewed until it is complete. (If you agree type your initials here)
*
If you agree type your initials here
Applicant Digital Signature:
*
Date
*
Submit
Home
Donate
Monetary Donation
K9 Events
FORGOTTEN WARRIOR MEMORIAL
Store
Black Hat
Veterans & Service Dogs
>
Camouflage Hat
Testimonials
Long Sleeve Tee
About Us
>
Vehicle Donation
Contact
Short Sleeve T
K9s For Veterans Patch
K9 Service Dog Application
Veterans Talk Show
Sponsors
Volunteer Opportunities
K9 TEAM MEMBERS
TRAINING STAFF
Training Day Videos
Schedule appointments
Training Update
Blog
Izip Alki Comfort 8 Bicycle Raffle
