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First name*

Last name*

Email

Phone

Which days are you available?*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

How did you hear about us?

Tell us about yourself and your need for a Service Dog?*

Have you previously worked with a Service Dog?*

Have you previously or currently owned /own a pet ?*

Service Status (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?*

What area of training will you require?

Additional Comments

Service Dog Application

Submit a Service Dog Application by filling out the form below and we will get back with you shortly.

Home
Programs
Sponsorships
Support
More of LifeLine
Shop
Apply Now
Contact

Home
Programs
Sponsorships
Support
More of LifeLine
Shop
Apply Now
Contact

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