FSD Service Dog Application

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Before filling out the application, we ask that you thoroughly review our website, particularly the "Service Dog FAQ", the criteria listed on the "Apply For A Service Dog" page, and the "Application Check List" to ensure that you qualify for our program. Freedom Service Dogs of America (FSD) serves several specific client types, and we unable to serve you if your needs are outside our predefined range of clientele. FSD does not discriminate on the basis of race, color, creed, national origin, sex, age, religion, marital status, sexual orientation, gender identity or expression, veteran status, HIV/AIDS status, physical or mental disability.


Saving Your Progress

You will likely need to complete the application in two or more sessions. To ensure your application and information are not lost, we strongly recommend that you utilize the "Save Progress and Return Later" feature, found in the upper right corner of the webpage. Please remember the password you set when using this feature, and check your email for a link that will allow you to open your partially completed application and resume your progress. If your application remains in progress and uncompleted for more than a year, it will be deleted and you will need to start a new application. 



Application Instructions

Expect the application completion process to take between 1 - 3 hours. During the completion of this application, you will be required download and upload files, and to print or email documents to your references. We strive to make the experience as user friendly as possible, but we encourage you to seek technological support from family or friends if you feel the need to do so.

 

If you are completing this application on behalf of an minor or 3rd party recipient, please complete as the individual receiving the dog.

 

In order to complete the application, you will be responsible for providing, identifying, and/or obtaining the following:

  • Two completed Emergency Support Contact forms, signed by a family member or friend
  • Two completed Letter of Reference forms, filled out and signed by non-family members
  • One Medical History form, signed and submitted by your primary care provider or mental health professional
  • Your own basic financial information to fill out our finance worksheet and proof of one month's income
  • DD214 for veteran and active duty military applicants

If you have any questions about your eligibility for the Freedom Service Dogs program or filling out the FSD application, please contact us at: 303.922.6231. You are also welcome to visit the FSD website at  www.FreedomServiceDogs.org.

Name










Current Address







Permanent Address








Demographic Information
We are gathering important demographic information to track progress on inclusivity and diversity measures being taken within our organization. To the extent you are comfortable, please select the options that best reflect how you identify.










Name of Transcriber



Hidden Fields



Application Information













Application (continued)

Please use the scale below to indicate physical ability. 

1 = No Use
10 = Full Use
1 2 3 4 5 6 7 8 9 10



Please use the scale below to indicate your ability. 
1 = Severe impairment/inability to be understood/inability to learn
10 = No impairment/ability to be understood/ability to learn
1 2 3 4 5 6 7 8 9 10




How do you handle the following?








Application (continued)






People in the Home
List the people living in your home besides yourself. Select 'add another person' and fill in the details for each individual.
Age Over 18




Age Under 18




















Condition Agreement

Do you agree to the following conditions?






















Instructions: To enter your signature below to authorize release of liability and indemnification, first type your name in the Name field. 

My signature below affirms that all statements above are true and correct.


Financial Impact

The below questions are meant for you to think critically about the financial impact a service dog may have on your life. While FSD does not charge our clients for a service dog, we do require that our clients assume the financial responsibility to care for your service dog, including (but not limited to) food, veterinary care, treats, toys, beds, and boarding. Please carefully consider the following questions.

Although the above amount of $3,000-5,000 per year is a good place to begin budgeting, unexpected veterinary occurrences can happen. Please read the following scenario and explain how you would respond to the circumstances. You have taken your dog to a dog park for some exercise and play. Your dog starts playing with another dog and they are tumbling around the yard. Later when you get home, your dog appears to be limping and cannot put any weight on one of his legs. You take your dog to the vet and find out that he has torn a ligament and needs surgery - a not uncommon occurrence in large dogs. The cost will be anywhere from $2,900-$3,200 for surgery and post-operative expenses.






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Please estimate the following expenses on a MONTHLY basis where applicable. (Enter '0' if not applicable.)


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$

$

$

$

$

Please take a moment to think critically about your monthly expenses and budget. Using this information and your current income, please fill out the following "Finance Worksheet" using your best estimates to map out what you can afford on a MONTHLY basis for your dog.


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$

$

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As a result of my application for an assistance dog from Freedom Service Dogs, Inc., I hereby release and discharge FSD and any successor, parent, affiliate, or subsidiary company of FSD, its present and former officers, directors, employees, independent contractors, volunteers, agents, representatives, legal representatives, accountants, attorneys, successors and assigns (“released parties”) from all claims, demands, and actions of any nature, known and unknown, arising out of, or related in any way to, any injuries or damages to any persons or property, including myself, caused directly or indirectly by this application for an assistance dog.

In the event that any person or entity brings any claims, demands, or actions of any nature against the released parties for any injury or damage to any persons or property caused directly or indirectly by this application for an assistance dog, I hereby agree to indemnify and hold harmless the released parties from any such liability or consequences.

Instructions: To enter your signature below to authorize release of liability and indemnification, type your name in the Name field. .


Medical Information

FSD requires a form to be completed by a physician or mental health professional to verify your diagnosis and that you would benefit from having a service dog. If you are a veteran with PTS, you are required to have this form completed by a mental health professional who can summarize your mental health and treatment received for PTS. The mental health professional must also address issues related to suicidal thoughts or actions and anger management coping skills. 


Your application will not be reviewed until Freedom Service Dogs has received a completed Medical History form, filled out by your therapist or primary care provider. Click here to download the form. Please complete and sign the first page only of the Medical History Form, then provide the full form (including the first page) to your medical practitioner. The form will then be completed and submitted directly to Freedom Service Dogs by your medical practitioner.


You are responsible for ensuring that your medical practitioner submits the completed form directly to Freedom Service Dogs in a timely manner. Submission instructions are on the last page of the form. 

Physician or Mental Health Professional's Name









My signature below authorizes you to release and discuss information regarding my medical records and condition to Freedom Service Dogs, Inc and/or consultants employed by Freedom Service Dogs, Inc. This information will be used to evaluate and assess my situation and is essential for FSD to train a service dog to increase my independence. All information is confidential. Parental or duly authorized consent is required, pursuant to state and federal law, if client is a minor, or under guardianship or conservatorship/ward of the court.

Instructions: To enter your signature below to authorize release of liability and indemnification, type your name in the Name field. 


My signature below confirms that the medical professional who will return the Medical Reference Form is my primary provider. I understand that I am responsible for ensuring the Medical Reference Form is given to my primary provider and sent to FSD. 

Instructions: To enter your signature below type your name in the Name field. 


References & Emergency Contact Information

References
Please list the name, email and phone number for two (2) individuals -- one a professional and one personal (cannot be a family member, partner or spouse) who will provide a letter of recommendation for you. You are required to upload the Letter of Recommendation from each of your references. Please download the Letter of Recommendation form and provide it to each reference before uploading below.
Reference 1





Reference 2





Emergency Contacts

Please note that each contact listed will need to provide written evidence that she/he is knowledgeable of your service dog application, they support the process and placement of a service dog and can provide a temporary home for the service dog should an emergency arise. 


You are required to upload an Emergency Contact Consent form for each of your emergency contacts. Please download the Emergency Contact Consent form and provide it to each of your emergency contacts before continuing through the application.

Emergency Contact 2










Emergency Contact 1










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