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Service Dog Application

First name

Last name

Email

Phone

How did you find out about us?

Which days are you available?

Mon

Tue

Wed

Thu

Fri

Sat

Tell us about yourself and your need for a service dogs.

Have you previously worked ith a Service Dog?

Have you previously or currently owned /own a pet ?

Please check one

Veteran

Active Duty

First Responder

Gold Star

Student

Family Member/Spouse (of any of the above)

Civilian

Branch of Service

Air Force

Army

Marine

Navy

U.S. Coast Guard

National Guard

Police

Paramedic/EMT

Fire and Rescue

Tell us what you hope a service dog can do for you?

Do you have a DD214?

Yes

No

What area of training will you require?

Diabetic Alert/Response

PTSD

TBI

Autism Assistance Dog

Mobility Assistance

Cardiac (POTS,Long QT etc)

Seizure Alert/Response

Hearing

Stroke Alert/Response

Allergen Detection

Migraine Alert

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Donations/Gifts can be mailed to :
LifeLine Service Dogs
P.O. Box 128
141 Well Yard Lane
Cove, AR 71937
Our 2023 W9 can be provided upon request by emailing lifelineservicedogscorp@gmail.com

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