Successor Dog Application

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Introduction

Completing a successor service dog application is an important step in helping Canines for Service (CFS) evaluate your current needs and determine the best service dog match. While you may have previously received a service dog from CFS, a successor application is considered a new application. All successor applicants must complete the full application process, including a virtual interview and application review by the Committee.

If approved, you will receive priority placement on the successor service dog waiting list. Each successor service dog placement is based on your individual needs and the availability of appropriately matched dogs in training. Because of this individualized matching process, the wait time for a successor service dog may be up to two years.

Please Note: Failure to provide complete and accurate information may impact your application status. Canines for Service reserves the right to remove an applicant from the application process or waiting list at any time. Incomplete applications will be closed after 30 days. Applicants must remain in good standing with CFS to remain eligible for a successor dog.

If you have questions about the application process, please contact our Veteran Services Coordinator at veteranservices@caninesforservice.org.

SUPPLEMENTAL INFORMATION

In addition to fully completing this application, the following items are required. All documents and files must be completed and submitted in order for your application to be reviewed.

Household Member Consent Form (If applicable)
Updated VA rating OR supplemental documentation
Updated Medical History Form
Updated Mental Health Form
Consent to Background Check Form
Home Tour Video

Documentation Agreement*

I understand that I am required to submit the required supplemental information outlined above in order to be considered for the CFS service dog program.

Contact Information

First Name*

Last Name*

Preferred Name*

Date of Birth*

Phone Number*

Email Address*

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Contact Method*

Demographics

Gender*

Race/Ethnicity*

Marital Status*

Household Income Level*

Criminal History

Have you ever been charged with, convicted of, or found not guilty by reason of insanity of any felony in a civilian or military jurisdiction that resulted in incarceration longer than sixty days?*

Yes

Please Explain (Felony)

Have you ever been charged with, convicted of, or found not guilty by reason of insanity of any misdemeanor in a civilian or military jurisdiction?*

Yes

Please Explain (Misdemeanor)

Background Check

Please upload a completed Consent to Background Check Form below.

Click Here To Download The Consent to Background Check Form

Consent To Background Check Form Upload

Max. file size: 300 MB.

Household Info

Does anyone else live in the household besides yourself?*

Yes

Please list names, ages, and relationship of the household members to you:

Do you have any children who do not live in the same household?*

Yes

Please list names, ages, and frequency of visits:

Do you currently have a spouse or significant other?*

Yes

Household Member/Significant Other Consent Form

Please upload the completed Household Member/Significant Other Consent Form below. This form MUST BE completed by the individuals themself, not the applicant.

Click Here To Download Household Member/Significant Other Consent Form

Household Member/Significant Other Form Upload

Max. file size: 300 MB.

Household Pets

Are there currently any pets beisdes your current service dog in your home?*

Yes

Please list breeds and ages of current pets:

Are you or anyone in your home allergic to dogs?*

Yes

Home Details

Do you own or rent your home?*

Own

Rent

Home Location*

Home Type*

Does your home have a yard?*

Yes

Is the yard fenced in?*

Yes

Have you lived at this residence for a minimum of 6 consecutive months?*

Yes

Proof Of Residency

Please upload documents to prove you've had consistent residency for the past 6 consecutive months. This may include a combination or your current and previous residence if you've recently moved (e.g. Utility Bills, Mortgage Statements, Rental/Lease Agreement).

Proof Of Residency Documents Upload

Drop files here or

Max. file size: 300 MB.

Home Tour Video

Please provide a video of your home. Show any pets you may have and a brief tour of the entire inside of your home, outside including any yard, and the street you live on. If video file is too large to upload, please email a download link to Ellie Gardner, Veteran Services Coordinator, at egardner@caninesforservice.org.

Home Tour Video Upload

Drop files here or

Max. file size: 300 MB.

Employment Information

Are you currently employed?*

Yes

Current Employer Name

Your Current Title

Please describe your work environment and job functions:

Is your employer aware that you are applying for a service dog?

Yes

Education Information

Highest Level Of Education*

Are you currently enrolled or plan to enroll in school?*

Yes

What school do you currently/plan to attend?

Where do you currently/plan to attend classes?

What degree are you pursuing?

Medical History

Height (in.)*

Please enter a number from 1 to 500.

Weight (lbs.)*

Please enter a number from 1 to 1000.

Verbal Skills (On a scale of 1 (non-verbal) to 10 (fluent with clear annunciation))*

Which service-connected conditions do you have? (Select All That Apply)*

Post-Traumatic Stress Disorder (PTSD)

Traumatic Brain Injury (TBI)

Mobility Limitations

Military Sexual Trauma

Primary Diagnosis/Disability*

Date of Onset or Diagnosis If Known

Secondary Diagnosis/Disability

Date of Onset or Diagnosis If Known

List any pertinent medical history:

List any upcoming surgeries or other medical events:

VA Disability Rating Letter (Include Disability Rating Percentage Breakdown) Upload*

Max. file size: 300 MB.

Please upload your most recent VA Rating Letter that includes the breakdown of your disability rating percentage.

Medical Devices

Do you currently use any adaptive equipment to assist you with your disability?*

Yes

Adaptive Equipment Used

Manual Wheelchair

Power Wheelchair

3-Wheel Scooter

Braces

Cane

Walker

Crutches

Other

Do you use any other medical devices? (e.g CPAP, Glucose Monitor)*

Yes

List your medical devices and frequency of use:

Symptom Experience

Please rate the following symptoms and their effect your daily function on a scale of 1 (does not limit daily function) to 10 (fully limits daily function). Please mark N/A for any symptoms you do not experience.

Distractibility*

Hallucinations*

Anxiety*

Feelings of Isolation*

Intrusive Imagery*

Hyper Vigilance*

Dissociation*

Fear*

Flashbacks*

Startle Response*

Avoidance Behaviors*

Nightmares*

Feelings Of Being Threatened*

Aggression*

Required Medical & Mental Health Forms

The following forms must be completed and returned to Canines for Service directly by your providers. Forms submitted by the applicant will not be accepted.

Download Medical History Form
Download Mental Health Form

Primary Care Provider

Please provide information for the Primary Care Provider we should expect the Medical Form from on your behalf.

Primary Care Provider's Name*

Primary Care Provider's Phone Number*

Primary Care Provider's Email Address

Primary Care Provider's Address*

Street Address Address Line 2 City State ZIP Code

Mental Health Provider

Please provide information for the Mental Health Provider we should expect the Mental Health Form from on your behalf.

Mental Health Provider's Name*

Mental Health Provider's Phone Number*

Mental Health Provider's Email Address

Mental Health Provider's Address*

Street Address Address Line 2 City State ZIP Code

Service Dog Program

What tasks does your current service dog do to assist you inside and outside the home?*

Where do you frequent on a regular basis with your current service dog? (i.e., which stores/restaurants, the gym, hobbies, public transportation, work/school environment, etc.)

What skill(s) is your service dog not doing for you now that you think your need?

Is there anything else you would like us to consider for your successor service dog?

Emergency Contact

Please list the best emergency contact in the event of an emergency with you or your potential service dog.

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Phone*

Emergency Contact Email*

Relationship To You*

Certification & Signature

Release Agreement*

In consideration for being an applicant and potential client of Canines for Service, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO HOLD RESPONSIBLE Canines for Service Inc., The State of North Carolina their officers, agents, servants, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, including court costs and attorney fees, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me.

Information Consent*

I give consent for the individuals listed throughout my application to release to Canines for Service information relating to my current health, mental health, and home/work/school environments. I understand that the information requested is confidential, will not be released to any person or agency outside Canines for Service, and will be used for the sole purpose of assessing my qualifications for a service dog and ability to provide a suitable home for a service dog.

Right to Remove Policy*

I understand that Canines for Service reserves the right to remove any successor applicant/CFS client from the application process or waitlist, at any time, for any reason.

Service Dog Commitment*

I recognize the importance of receiving a service dog and understand it can be a 10+ year commitment. I am aware of the obligations I will have if approved and agree to follow all protocols outlined by Canines for Service to remain in compliance.

Financial Responsibility*

I understand there is no cost to receive a service dog from Canines for Service, but if approved I will be financially responsible for the maintenance and care of the service dog for the entirety of his or her life acknowledge and can uphold the financial obligation of an average annual cost of $2,000.

Accuracy Certification*

I certify that, to the best of my knowledge and belief, the information provided in this document truly represents my needs and present situation. I understand that my failure to provide complete, accurate, and honest information herein will permanently disqualify me and will result in my immediate removal from the Canines for Service service dog program.

Review & Grievance Policy*

I understand that applicants have the right to express concerns regarding their application and the review committee decision. Grievances must be reported in writing to the Veteran Services Coordinator, Executive Director or a Board Member within than 60 days of the incident. The client can expect a review of the grievance and response from an appropriate staff member within 90 days of the grievance submission.

Applicant Signature*

Your Name
Your Name
Your Name

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