Scholarship Application

To be considered for a scholarship, please complete be below form.

    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: *

    MaleFemale
    Applicant Address:*

    Applicant Email

    Applicant Home Phone

    Applicant Work Phone

    Applicant Birthdate: ,

    Disability Information

    Briefly tell us about your disability in your own words:

    Is your disability progressive? * YesNo
    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):

    Name: *
    Address:*

    Email: *
    Phone: *

    Second Personal Reference (cannot be related to you):

    Name: *
    Address:*

    Email: *
    Phone: *

    Medical/Professional Reference (cannot be related to you):

    Name: *
    Phone: *
    Contact information:*

    Additional Comments

    Please note: If you hit submit and the page does not change, please check over your answers to ensure you’ve filled out the form completely.

    Community & Corporate Leaders