NORTHWEST BATTLE BUDDIESApplication for Service Dog

NORTHWEST BATTLE BUDDIES

Application for Service Dog

Serving our Veterans who served us all

MUST BE A HONORABLY DISCHARGED VETERAN TO APPLY

Today's Date*

DEMOGRAPHICS

Given Name*

AKA

What would you like us to call you

DOB*

Address*

City*

State*

Zip Code*

Email*

Cell Phone*

Home Phone

What is your preferred method of contact*

Select or enter value

How did you hear about us? Referral, Google, etc.

Physical History

Please describe any physical limitations or medical conditions*

(i.e. TBI, back issues, mobile issues, be specific)

List any medical devices you use regularly*

(i.e. cane, walker, wheelchair, CPAP)

Diagnosed with a TBI?*

Select

Do you have Hearing loss*

Select or enter value

Degree of Hearing loss*

Do you have Vision loss*

Select or enter value

Degree of Vision loss*

Describe your daily routine*

How comfortable are you out in public, please explain?*

Service Dog Information

Have you previously used a Service Dog*

Select or enter value

Are you able to adequately maintain a Service Dog*

Food, Equipment and Veterinary Care - (approx. $200/month)

Select or enter value

I am a Combat Veteran*

Select or enter value

I was Honorably Discharged*

Select or enter value

I am diagnosed with PTSD*

Select or enter value

I have only used prescribed medications in the past three years*

(Substance abuse will ABSOLUTELY not be tolerated.)

Select or enter value

I have been clean and sober for at least three years at the time of this application*

Select or enter value

Do you agree to a background check?*

Select

Do you plan on relocating, moving, or deploying outside of the United States in the next six years?*

Yes

Maybe

Additional Information Needed

Please upload the required forms

DD214*

(If you are currently Active Duty, please contact Veteran Liaison jona@northwestbattlebuddies.org or call 360-558-2049)

Drag and drop files here or

Send me a copy of my responses

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