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

Request Filled Out By: *

Relationship: *

Contact Email

Applicant Name: *

MaleFemale
Applicant Address:*

Applicant Email

Applicant Home Phone

Applicant Work Phone

Applicant Birthdate: ,

Briefly tell us about your disability in your own words:

Is your disability progressive? * YesNo
If yes, please explain:

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

How did you hear about CDK?

Name: *
Address:*

Email: *
Phone: *

Name: *
Address:*

Email: *
Phone: *

Name: *
Phone: *
Contact information:*

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.