Scholarship Application

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: JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031,

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