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home
projects
Service dog training
resources
application
about us
F.A.Q
Our mission
Finances
Donate
Application Form
Contact Information
Veteran's Name
*
Veteran's Name *
Address Line 1
*
Address Line 1 *
Address Line 2
Address Line 2
City
*
City *
Zip
*
Zip *
Date of Birth
*
Date of Birth *
Primary Phone Number
*
Primary Phone Number *
Alternate Phone Number
Alternate Phone Number
Email
*
Email *
Emergency Contact Information
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Phone
Emergency Contact Email
Emergency Contact Email
Medical Information
Physician's Name
Physician's Name
Physician's Phone
Physician's Phone
What is your primary diagnosis?
What is your primary diagnosis?
Please describe any limitations you experience in your everyday life.
Please describe any limitations you experience in your everyday life.
May we contact your physician?
Do you have a diagnosis of PTSD from a licensed mental health care provider?
Medical Equipment
Other Equipment
Other Equipment
Crutches
Braces
Hearing Aids
Wheelchair
Oxygen Tank
Home Information
Type of Home
Type of Home
Additional Comments
Additional Comments
Where do you plan to exercise a dog?
Where do you plan to exercise a dog?
Where would the dog be while you are away?
Where would the dog be while you are away?
How many hours per day would the dog be alone?
How many hours per day would the dog be alone?
How often do you travel?
How often do you travel?
Do you own your residence?
Are you applying to adopt a specific Warriors Keep dog?
Do you have a fenced yard?
Would you take the dog with you on trips?
Do you or any household members have allergies to dogs?
Do you currently have a veterinarian you use?
Note: We are required to contact your veterinarian for medical history to meet the standards for our certification with Assistance Dogs International (ADI).
Employment Information
Are you employed?
School Information
Do you attend school?
Canine Information
Where do you plan to house a dog?
Where do you plan to house a dog?
What is your experience with dog care and training?
What is your experience with dog care and training?
Why do you want to train a service dog?
Why do you want to train a service dog?
Do you already have a dog you would like to train as a service dog?
Are you able to handle a dog on your own?
Can you feed a dog on your own?
Can you walk a dog on your own?
Can you groom a dog on your own?
Can you verbally communicate with a dog?
Can you give hand signals to a dog?
Can you afford yearly veterinary visits?
Can you afford to groom the dog?
Have you or anyone in your home ever been investigated for animal neglect or cruelty?
*A service dog handler must be able to communicate with the dog either verbally or using a signed language.
References
Reference 1 Name
Reference 1 Name
Reference 1 Phone Number
Reference 1 Phone Number
Reference 1 Email
Reference 1 Email
Reference 1 Relation
Reference 1 Relation
Reference 2 Name
Reference 2 Name
Reference 2 Phone Number
Reference 2 Phone Number
Reference 2 Email
Reference 2 Email
Reference 2 Relation
Reference 2 Relation
Residents Living in Your Home
Name
Name
Age
Age
Relationship
Relationship
Add
Pets Living in Your Home
Type (dog, cat, other)
Type (dog, cat, other)
Age
Age
Spayed or Neutered
Add
Attachments
Drag and drop files here, or click to select files
Disclaimer
I hereby acknowledge and understand that Warriors Keep reserves the right to deny service to an applicant for any reason, including but not limited to failure to meet the established criteria for receiving a service dog or that requires services that are not able to train. Warriors Keep provides specialized PTSD training and education relating to training a PTSD service dog. We do not provide any mental health counseling. We highly recommend all Veterans with PTSD to utilize Veterans Health administration or a Vet Center. I understand that if I can't complete the service dog program for whatever reason, the service dog is returned to Warriors Keep. Warriors Keep also reserves the right to remove a program service dog from a home at any time for mistreatment/neglect or an inappropriate match. I do hereby agree to hold free from any and all liability the Warriors Keep and its members and officers. I declare myself to be physically sound to participate with the Warriors Keep organization. My family, members of my household, and myself waive the rights and claims for damages and injuries, which may come from a connection and participation with Warriors Keep.
I READ, UNDERSTAND, AND AGREE TO THIS DISCLAIMER
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