Section 1: Application Information


Child's Name:


Diagnosis:


Birthday:


Address:


Age:

  Gender:

Section 2: Service Dog Training Information


Training Organization supplying your service dog:


Name & Contact at Training Organization:


What kind of service dog are you requesting?:


Estimated Cost of your service dog:


How much have you raised?:


Current Fundraising efforts (events, public support etc.):



Section 3: Parent/Guardian Information


Parent or Guardian's Name:


Phone Number:


Email Address:


Gross Monthly Income:


Employer & Job Title:



Section 4: Briefly tell us how a service dog would benefit your child


Describe the benefit below:


Have you been accepted by an approved dog service provider?:

Section 5: Funding


How will your family continue to fundraise for a service dog? :



Section 6: Parent/Guardian Certification


I certify that the information given in this application is true and correct as of the date set forth opposite my signature and that any intentional misrepresentation of the information contained in the application will result in the loss of current and future assistance from Angel Dogs and may result in civil liability. The applicant releases the Pearce Family Foundation from any and all liability which may arise from the sharing of this information to third-parties. The Pearce Family Foundation reserves the right to run a background check on every applicant.

Parent or Guardian's Name (signature):


Date:


Relationship to Patient:


I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Validation Code from Graphic:




 

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Pearce Family Foundation | 5321 E. Washington St. | Phoenix, AZ 85034 | info@pffarizona.com

Copyright 2018 Pearce Family Foundation - All Rights Reserved