Manual wheelchair Wrist brace Hearing aid Crutch / cane Walker Other: _____________________________________________________________________________ Describe any other medical problems you have: How do these affect your daily living skills? Part 4 How Could a Service Dog Help – What activities are you currently not performing that you believe a service animal would allow you to perform? If you previously had a service animal that you no longer have, what activities did the service animal allow you to do which you currently cannot do? If you currently have or previously had a pet, which activities does / did the pet allow you to do which you currently seek a service dog to enable? If you currently have or previously had a pet that enabled you to do an activity you cannot do without the pet, why do you believe another pet allow you to perform the activity? wouldn’t
Manual wheelchair Wrist brace Hearing aid Crutch / cane Walker Other: _____________________________________________________________________________ Describe any other medical problems you have: How do these affect your daily living skills? Part 4 – How Could a Service Dog Help What activities are you currently not performing that you believe a service animal would allow you to perform? If you previously had a service animal that you no longer have, what activities did the service animal allow you to do which you currently cannot do? If you currently have or previously had a pet, which activities does / did the pet allow you to do which you currently seek a service dog to enable? If you currently have or previously had a pet that enabled you to do an activity you cannot do without the pet, why do you believe another pet wouldn’t allow you to perform the activity?
VMF-Service-Dog-Application_June-2017-1.docx