Apply Now – Saber Life Foundation

Service Dog Application

Please fill out all required fields (ending with *). Once submitted, the form will then be sent directly to the Saber Life Foundation email for review.

Click here to read the Applicant Selection Process.

"*" indicates required fields

Step 1 of 3

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Acknowledgement*

Check here to acknowledge that you have read the Applicant Selection Process

Contact Name*

First Last

Date of Birth*

Month

Day

Year

Contact Email Address*

Primary Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone Number*

Alternate Phone Number*

Gender*

Male

Female

Marital Status*

Single

Married

Widowed

Divorced

Please provide an emergency contact who is someone not living in the household where the service dog will be residing.

Emergency Contact Name*

First Last

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Phone Number*

Please indicate your relationship to the emergency contact*

Parent

Grandparent

Other Relative

Friend

Colleague

Please provide your annual gross income below. We are requesting that you include all sources of income. Please include earned income (wages), alimony, child support, disability income, public assistance, rental income, investment income, social security or SSI, unemployment benefits, veteran income, workers compensation and pension income.

Annual Gross Income*

Recipient is defined as the individual or Veteran with disability or disabilities that is in potential need of a service dog.

Will the service dog be for you?*

Yes

Recipient Name*

First Last

Recipient Date of Birth*

Month

Day

Year

Recipient Gender*

Male

Female

Please list names, relationship and age of members that would primarily be living with the recipient

Name	Relationship	Age	Actions
There are no Family Members.

Maximum number of family members reached.

Do any of the above household members have an allergy to pet dander?*

Yes

Does the recipient have an adult (18+ year old) attendant?*

Yes

Attendant's Name*

First Last

Attendant's Address*

Street Address Address Line 2 City State ZIP Code

Attendant's Phone Number*

Is the attendant able to accompany the recipient to public access training?*

Yes

Is the recipient's present disability the result of an accident?*

Yes

Please describe*

Is the recipient's disability progressive?*

Yes

Does the recipient currently use any medical assisted devices?*

Wheelchair

Power Chair

Cane

Prosthetic

Hearing Aid

Communication Aid

Walker

Leg Brace

Other

None

If other, please describe*

Do you currently own a dog?*

Yes

Please list the bread of the dog*

Please describe your experience with the dog*

The information provided will help the trainer with the types of tasks and duties the service dog should be trained to perform. Please answer all questions to the best of your ability.

Please check the box(es) for the applicable medical conditions of the recipient.

Mental/Psychiatric Disabilities*

Depression and Depressive Disorders

Anxiety Disorders and Phobias

Bipolar Disorders

Schizophrenia and Psychotic Disorders

Attention Deficit Hyperactive Disorder (ADD/ADHD)

Addiction, Substance Abuse, and Alcoholism

PTSD, Trauma, and Stress Related Disorders

Obsessive Compulsive Disorders (OCD)

Oppositional Defiance Disorder (ODD)

Disruptive Mood Dysregulation Disorder (DMDD)

Dissociative and Personality Disorders

Autism (Verbal)

Autism (Non-Verbal)

Neurocognitive and Sleep-Wave Disorders

Other

None

If other, please describe

Physical Disabilities*

Multiple Sclerosis (MS)

Sensory Disabilities (Blind, Deaf, etc.)

ALS (Lou Gehrig’s Disease)

Cancer

Cerebral Palsy

Parkinson’s Disease

Muscular Dystrophy

Spinal Cord Injury

Arthritis

Diabetes

Chronic Pain

Stroke

Paralysis

Vertigo

Epilepsy (Tonic)

Epilepsy (Clonic)

Epilepsy (Tonic-Clonic)

Other

None of the Above

If other, please describe

Check the box(es) for demonstrated behavior(s) with the above diagnosis*

Eloping

Animal Cruelty

Object Aggression

Self-Harm

Inappropriate Sexual Behavior

Physical Aggression

Harm to Others

None of the Above

Check the box(es) for settings to which the service dog will frequently encounter or travel to*

Grade School

High School

College/University

Grocery store

Sporting event or large gathering (100+ people)

Work

Restaurant

Religious setting

Airplane

Hospital/Doctor

Dog will go between two homes (i.e. divorced parents)

None of the Above

Check the box(es) for environmental conditions which the service dog would encounter in the recipient’s primary home.

Primary Dwelling Type*

House

Apartment

Town House

Condominium

Manufactured (mobile) Home

Household*

Infant

Toddler

Teenager

Adult

Elderly

Animals (not including service dog)*

Cat(s)

Dog(s)

Small Animal(s) (e.g. rodents, birds)

Farm Animal(s)

Reptile(s)

None

Environment*

Smoking

Non-smoking

Swimming Pool

Natural Body of Water

Elevator

Stairs

Fenced Yard

Non-Fenced Yard

Check the box which best describes where the dog will be on the following days.

Monday – Friday*

The dog will remain in a kennel for 6-8 hours while I/we are at work/school.

The dog will have free roam for 6-8 hours while I/we are at work/school.

The dog will sometimes accompany me to work/school and not remain at home.

The dog will always accompany me to work/school and not remain at home.

I will largely be present with the dog at home.

Saturday – Sunday*

The dog will remain in a kennel when I/we are not at home.

The dog will have free roam when I/we are not at home.

The dog will sometime accompany me/us to activities on the weekend.

The dog will always accompany me/us to activities on the weekend.

I will largely be present with the dog at home.

Please finalize the application with your signature*

Name

This field is for validation purposes and should be left unchanged.

Service Dog Application

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