Application

NEADS Social Dog for a Child

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  = Required Information

Personal Information

A child must be six years of age or older at the time of application. All social dogs are Labrador Retrievers.
Child's First Name
Child's Last name
Guardian's First Name
Guardian's Last Name
Guardian's Relationship to Child
Street Address
City
State
Postal Code
Phone Number
Email
Child's Date of Birth
Month
Day
Year
In case of emergency, name of a relative we can call if we could not reach you.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone
Emergency Contact Relationship

School Information

School Name
School Street Address
School State
School Postal Code
Current Grade

Medical History

Please give us a brief history of your child's disability. (Please do not include abbreviations or initials when discussing disabilities.)
Have you discussed this application with your child's doctor?
Is your child allergic to cats?
Is your child allergic to dogs?
Is anyone in your household allergic to dogs?
Please list any equipment that your child uses for his/her disability.
Does your child have any other physical limitations that we should consider when choosing a dog for you?
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