Susquehanna Service Dogs

Application Process

If you haven't already done so, PLEASE REVIEW the Application Process before completing this form.

Preliminary Application Form

To begin the application procedure to receive a Service Dog, Balance, or Hearing Dog, please provide the following information:

* denotes required information

Contact Information

Title (Mr, Ms, etc.)*
Full Legal Name*
Name of parent or guardian if applicant is a child:

Street or PO Address*
City*
State*
ZIP*
County*
Home Phone*
Work Phone
Date of Birth*
Occupation
E-mail*

Service Dog Information

Please describe your disability, including information about its onset, and prognosis. (Specifically, what are your limitations, do you have an electric or manual wheelchair, do you use a communication board, hearing aids, etc.?)*

What type of Dog do you feel would meet your needs?*
	Service Dog
	Balance Dog
	Hearing Dog
	Other (explain)

Please explain why you want an Assistance Dog.*

What needs or services do you feel an Assistance Dog can provide for you?*

Comments

Additional comments you may wish to share with the Partner Selection Committee:

When you have completed the entire form, please click on the SUBMIT APPLICATION button below. Your request will be forwarded to the Partner Selection Committee, and processed as soon as possible.

PLEASE NOTE that Susquehanna Service Dogs places dogs only within the state of Pennsylvania, and selected out-of-state locations.

Keystone Human Services