Application

Need a Battle Buddy?

Please fill out the application below.

Please Fill Out The Form Below!

Name*
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
DOB*
MM slash DD slash YYYY
Gender
- F
- M
- Non-Binary
Emergency Contact Name
Emergency Contact Number
Marital Status
How Many People Live in Your Household
Are you currently working
Are you enrolled in School
Do you have a caretaker
Is anyone in your home allergic to dogs
Do you have pets
If Yes, are they all up to date with vaccinations
Living Conditions
Other
Own or Rent?
If you were to become hospitalized, who would care for your service dog
Are you able to feed, walk and groom the service animal
MEDICAL INFORMATION
Have you been diagnosed with Post Traumatic Stress*
Have you ever been diagnosed with Traumatic Brain Injury
Are you a Survivor of Sexual of Military Sexual Injury/Trauma
Name of the Medical Center/Physician that determined the diagnosis
Address of Center/Physician
Harming Yourself?
Harming An Animal?
Violent with others
Please provide 3 personal references and their phone numbers. One of which may not be a relative or someone living with you.
Name
Number
Name
Number
Name
Number
Military Service Information.
Branch of Service*
Entered Active Service Date
MM slash DD slash YYYY
Discharge Date
MM slash DD slash YYYY
Entered Active Service MOS/Rate
Discharge MOS/Rate
I hereby agree to the following statement:
V.E.T. Service Dogs NFP has authority and permission to contact any person you have referenced on this form.
Signature*
Date
MM slash DD slash YYYY
Please submit a copy of a signed letter from a doctor, psychiatrist, psychologist or therapist that has diagnosed your condition of PTSI, TBI, MSI. You can also supply a rating from V.A Please scan and submit a copy of your D.D. 214, and please block out social security number
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Additional Information
Name
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If you would like any assistance, please call us directly at (708) 274-7678

Application

Need a Battle Buddy?

Please fill out the application below.

Please Fill Out The Form Below!

MEDICAL INFORMATION

Military Service Information.

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