Application

Sit Service Dogs Application

Your Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell(Required)

Home Phone

Your Email Address(Required)

Enter Email Confirm Email

Alternative Contact(Required)

Relationship(Required)

Phone(Required)

Applicant D.O.B.(Required)

Preferred Pronouns

Primary Diagnosis(Required)

Any Secondary Diagnoses

Doctor's Name(Required)

Office Name (If Applicable)

Office Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone(Required)

Please describe the most significant symptoms of your disability(s) and how it affects your daily life:(Required)

Do you participate in any types of therapy (if yes, please include types, frequency and duration)?(Required)

What types of adaptive equipment do you use? For example, a wheelchair, crutches, hearing aids, etc…? (if applicable)

Are you employed?(Required)

If Yes Please fill out the following Information:

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

May We Contact?

Basic Job Duties

Hours

Household Information(Required)

Household Information I currently reside in a

Do you have access to a fenced yard/enclosed area?(Required)

Other members of your household: (please include any live in aids or assistance) Name: Age: Relationship:(Required)

Are there pets in the home? (list species, breed, age, indoor/outdoor, and sex)(Required)

Owning a Service Dog:(Required)

Are you physically able to care for the dog alone?

If you do not feel you are capable of caring for the dog alone, who will be assisting you the dog? Please explain(Required)

Will you be able to feed the dog?(Required)

Will you be able to regularly groom the dog?(Required)

We realize some individuals may need assistance from other sources to care for their service dog. Clients may contract outside assistance to help with chores such as feeding, grooming, attending veterinary appoints, etc… Often times, it is possible for a client to arrange to care for his/her dog with a few adjustments; for example, having a friend pre-measure dog food into baggies once a week so that you can empty the baggies directly into the dog’s dish throughout the week, or using a professional groomer. The information on this application is correct to the best of my knowledge.

Applicant Signature(Required)

Date(Required)

SIT reserves the right to deny services to any applicant who does not meet the criteria necessary for placement of a service dog or who requires services not trainable within the guidelines of the agency. This application does not constitute a contract between Sit Service Dogs and the applicant indicated above.

Application

Sit Service Dogs Application

SIT

Service Dogs

Quick Links

Call Us Today!

(618) 426-5666