Service Dog Registration

Dog's Name:

Dog Will Assist With: Please choose a condition Arthritis Relief Ataxia Autism Blindness / Seeing-Eye Dog Cardiopulmonary Condition Diabetes Alert Impaired Hearing Localized Trauma Mobility Issues Multiple Sclerosis Panic Attacks PTSD / Psychiatric Reflex Sympathetic Dystrophy Retrieval of Medicine Seizure Alert Speech Impairment Stroke Other Prefer Not to Say

(If multiple, select one that best describes the condition.)

Handler's First and Last Name:

Your Email Address:

Confirm Your Email Address: