Service Dog Application
When filling out this form, answer questions for the person who will be using the service dog, referred to as APPLICANT, unless otherwise specified.
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Email *
Please indicate your interest - check all that may apply *
Required
If you would like to possibly have your own dog trained, please give as much information about the dog as possible, to include breed(s), age, training history, behavioral history, any public access experience, etc. If you are not interested in us training your dog, please skip this question. Please do not acquire a dog for this purpose without speaking to us first.
Applicant's First and Last Name (Who will be using the service dog?) *
Applicant's (the person using the service dog) Date Of Birth *
MM
/
DD
/
YYYY
Applicant's Gender *
Height (In Inches) *
Weight (In Pounds) *
Where are you in the process of obtaining a service dog? *
Please list any questions or readiness information regarding the above question. *
List Names And Ages Of All Persons Living In The Home With The Applicant/ Child *
Primay Phone Number *
Valid E-mail Address - this will be used for all contact with you. If it changes, please email us at merlinskids.servicedogs@gmail.com. Please use the same one you used to send the dr note *
Address- must include city and zip code *
State *
How or from who did learn about Merlin's KIDS? *
Job Description (parents if applying for a child) *
Parent/ Guardian Full Name (s) (put n/a if applicant is an adult) *
Address Of Guardian/ Caregiver only if different than Applicant's Address, including shared custody arrangements  
Relationship To Applicant/ Child *
Define The Applicant/ Child's Disability (Be As Specific As You Can) *
Cause Of Applicant's/ Child's Disability (Be As Specific As You Can) *
Define the Applicant's/ Child's Specific Need For A Service Dog and what tasks you would want the service dog to perform (Be As Specific As You Can) *
Do you want the dog to attend school with the child? *
Check All Equipment In Use Currently *
Required
Do You Have Any Other Pets? *
If Yes, List Gender, Type Of Pet, Spay/Neuter, Age, Size, Weight, Breed  
Do You Have A Fenced In Yard? *
If No, Please Explain Location For Exercise And Bathroom For The Dog
Merlin's KIDS can only place dogs as funding is available.  Dogs commonly cost between $24,000 to $30,000. Merlin’s Kids subsidizes a portion of the cost and encourage families to fund raise  between $15,000 to $18,000. We ask each family to fund raise and/or apply for grants, much of which can be done online. *
If You Already Have Funds raised to donate, or would like to get started on fundraising, please add any specific information below.  
Electronic Signature: by typing my name below, I validate that all information is complete and correct.  I understand that this is an initial inquiry, to be followed by a full application packet if chosen to move forward in the process.  I understand that I will travel to NJ or MO for an evaluation if selected, and that I will be expected to fundraise for Merlin's KIDS, a 501c3 nonprofit.  
Please write any additional thoughts or questions you have regarding your initial application.
A copy of your responses will be emailed to the address you provided.
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