Canines For Disabled Kids Scholarship Application

General

Training organization supplying service dog

Name of contact at training organization

Applicant Information

About You

Request Filled Out By

Relationship

Contact Email

About The Applicant

Applicant Name

Applicant Email

Gender

Male

Female

Applicant Address

City

State/Province

Zip/Postal

Country

Preferred Phone

Work

Cell

Home

Applicant Work Phone

Applicant Cell Phone

Applicant Home Phone

Date of Birth

Disability Information

Briefly tell us about your disability in your own words

Is your disability progressive?

Yes

No

If yes, please explain

You needs and expectations

Why Do You Want A Service Dog?

Please describe how your disability affects your life, the lives of the people close to you

What is your current level of independence? What special tasks/skills will your service dog perform for you?

How will your independence change with the aid of your service dog

References

How did you hear about CDK?

First Personal Reference (cannot be related to you)

First Personal Reference - Name

First Personal Reference - Address

First Personal Reference - Email

First Personal Reference - Phone

Second Personal Reference (cannot be related to you)

Second Personal Reference - Name

Second Personal Reference - Address

Second Personal Reference - Email

Second Personal Reference - Phone

Medical/Professional Reference (cannot be related to you)

Medical/Professional Reference - Name

Medical/Professional Reference - Phone

Medical/Professional Reference - Contact Information

Additional Comments

Captcha

Scholarship Application

General

Applicant Information

About You

About The Applicant

Disability Information

You needs and expectations

References

First Personal Reference (cannot be related to you)

Second Personal Reference (cannot be related to you)

Medical/Professional Reference (cannot be related to you)

Additional Comments

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