Application for Veterans and Service Members

Application for Military Veterans and Retired First Responders

Thank you so much for your interest in our Pups4Patriots™ program! We appreciate your interest and look forward to the possibility of matching you with a service dog. To qualify, you must:
- Be a military veteran or retired first responder
- Have a service-related post-traumatic stress (PTS) and/or a traumatic brain injury (TBI) diagnosis from a mental health professional
- Be participating in regular mental health treatment (your clinician will need to submit a form)
*Please note: We don't provide guide dogs, hearing dogs, or mobility dogs.
Basic Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Gender*
Current Employer
Type NA if not applicable
Military / First Responder Service
Branch / Type of First Responder*
Rank*
*for first responders, put N/A
Type of Discharge*
Please list the dates and locations of your combat deployment(s)?*
Date - Deployment location*for first responders, put when and where you served
Questions
Have you been diagnosed with service-related PTS and/or TBI by a healthcare professional?*

YesNo
Are you currently receiving mental health treatment for PTS/TBI?*

YesNo
Have you ever been denied a service dog through another organization?*

YesNo
Is there anyone else living in your home?*

YesNo
If yes, please list each household member’s age and relationship to you*
Example: Daughter (10)
If yes, please specify
If there are children living in your home, please write down their age
Do you have a pet dog or other animal at home?*

YesNo
If yes, please specify*
Also write down their type, age and breed
Are you or anyone else in your home allergic to dogs?*

YesNo
Are you able to financially support the care of a service dog over the course of their lifetime? (We estimate the cost of a service dog to be approximately $2,000 per year)*

YesNo
Please provide us with an explanation of why you believe a service dog will help your symptoms and improve your quality of life day-to-day:*
Please note: We don't provide guide dogs, hearing dogs, or mobility dogs
How did you hear about us?*
If you have any questions or concerns about this application, please email infomilitaryaffairs@americanhumane.org.
Should be Empty:

Basic Information

Military / First Responder Service

Questions