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Service Dog Request
Please complete the form below to submit your request.
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Name
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First
Last
Address
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City
State
Zip Code
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Contact Phone Number
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Email
*
Select Preference
*
Puppy
Dog
Select Preference
*
Male
Female
No Preference
Breed
*
i.e. German Shepherd, Labrador Retriever, no preference, etc.
Disability the Dog Will Serve
*
i.e. epilepsy, autism, mobility impairment, blindness, etc.
Training Support in the Area
*
No
Yes
Unknown
Will there be training support for the service dog in your area?
Comments
*
Please share the individual's story and how you hope they will benefit from a service dog.
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