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Scholarship Application
To be considered for a scholarship, please complete be below form.
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 Street Address
*
City
*
State
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
*
Applicant Work 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
Additional Comments
reCAPTCHA
If you are human, leave this field blank.
Submit Application
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