Assistance Dog Application Request

assistance dogs application

Keystone Human Services KHS

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Keystone Human Services (KHS) is a non-profit organization that is a part of a global movement to provide support and expertise to people with disabilities.

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Keystone Human Services assistance dogs application

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Assistance Dog Application Request

Before completing this form, make sure you have reviewed the eligibility requirements on our Apply Now page.

Download an application request form

Contact Information - ** indicates required fields

Name of Applicant^**

Name of Parent or Guardian if applicant is a minor
If applicant is a minor, please enter the Parents' or Guardians' name.

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

County^**

Home Telephone Number

Work Telephone Number

Cell Phone Number^**

Primary E-mail Address^**

Secondary E-mail Address

Date of Birth^**

Occupation or Occupation of Parents/Guardians^**

Are you a U.S. veteran?^**

Environment Information - ** indicates required fields

Do you have experience living with and caring for dogs?^**

Please Explain^**

Do you currently have pets?^**

If Yes, how many?

If Yes, what types?

If you have pet dogs, are they spayed or neutered?

Are your pets friendly with other animals and people?

If No, Please Explain

Do you have a strong support system?^**

If applicant is a minor, are all parents or guardians willing to accept an assistance dog in their minor’s life?

Will the dog attend school or work with the applicant?^**

If yes, please describe the school or work environment.

Please review the above information prior to submitting.
If correct, submit the information using the button below.