K9 NAVIGATORS Inc.
Assistance Dog Application
(All information is privileged and will be considered confidential)
Name:
DOB:
Address:
City:
State:
Home telephone:
Zip code:
Work telephone:
In what format would you like to receive correspondence and information? Print:
E-mail:
Referred to K9 Navigators by:
Are you active duty U.S. Military: Yes:
No:
If yes, which branch:
Have you been discharged from the U.S. Military: Yes:
Have you had physical therapy?
Currently
No:
Type of Discharge:
In the past (if within five years, please provide
agency information)
Name of agency/hospital
Date training completed:
Address:
City:
State:
Contact person:
Phone:
Zip Code:
Please check all that apply to you:
Amputee
Coordination Issues
Muscle Damage
Support Can
Wheelchair
TBI
Hearing loss
Other
Please describe any physical limitations or medical conditions:
Have you previously used an assistance dog? Yes:
How many assistance dogs have you had?
Date you received first assistance dog?
K9 Navigators Inc
No:
Phone: 910-546-9338
K9 NAVIGATORS Inc.
Assistance Dog Application (cont’d)
(All information is privileged and will be considered confidential)
Date you last used a assistance dog?
Schools where you had assistance dog training?
Have you ever applied to another school for a assistance dog? Yes:
No:
Please List Schools and Status of Application:
Have you ever been rejected by another assistance dog school? Yes:
No:
If yes, please indicate which school(s) and explain:
Are you able to maintain a assistance dog? Yes:
No:
(food is approximately $40/month, plus veterinary care)
Emergency Information
Please list three people (in order of preference) to notify in case of an emergency:
Name:
Telephone:
Address:
Name:
Telephone:
Address:
Name:
Telephone:
Address:
I understand completing this application does not place me or the organization under any obligation. It
assists the organization in assessing my needs and eligibility for training with an assistance dog. The
organization does not discriminate against any applicant for admission to our program based upon race,
religion, color, national origins, ancestry, age, marital status, gender, or any other factor prohibited
under local, state or federal laws.
I hereby declare the above statements are true and have been answered to the best of my knowledge.
_______________________________________
______________________
Signature of applicant or guardian if applicable
Date
K9 Navigators Inc
Phone: 910-546-9338
K9 NAVIGATORS Inc.
Assistance Dog Application (cont’d)
(All information is privileged and will be considered confidential)
I,
hereby give K9 Navigators
permission to obtain any information, including medical, which will assist me in obtaining a
service dog.
Signature:
Branch of Service:
Rank:
Last 4 (SSN):
Date:
K9 Navigators Inc
Phone: 910-546-9338
K9 NAVIGATORS Inc.
Assistance Dog Application (cont’d)
(All information is privileged and will be considered confidential)
Medical References
To determine your eligibility, we will need the following information. You must provide contact
information for your PCM. Please fill in the other specialists if applicable.
Primary Care Manager (PCM):
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
Behavioral Health Professional
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
Physical Therapist
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
Occupational Therapist
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
Neurologist
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
Orthopedist
Name, rank if applicable:
Telephone:
E-mail:
Hospital/location of care:
K9 Navigators Inc
Phone: 910-546-9338
K9 NAVIGATORS Inc.
Assistance Dog Application (cont’d)
(All information is privileged and will be considered confidential)
Publicity Release
I,
recognize that K9 Navigators is an
Independent Organization We have several donors that provided the funds to
assist K9 Navigators acquire, train and provide Assistance Dogs to veterans and
active military injured in the current conflicts at no charge to the recipient.
I agree to allow these donors and K9 Navigators the use of my photographs with
my Assistance Dog: to promote the work and accomplishments that all
organizations conduct for sole purpose of assisting veterans. This includes use of
my photograph for newspaper articles, videos and brochures for the purpose of
fund raising and education. I understand that I am under no obligation to promote
or fund K9 Navigators Inc. However, we would like if you take into consideration
helping K9 Navigators Inc. with fund raising activities.
Date:
Signed:
Recipient
Printing your name here constitutes an electric signature.
K9 Navigators Inc
Phone: 910-546-9338