Application Checklist
To be eligible to enter Wolfhounds Legacy Assistant Dogs program you must be a veteran or first responder:
Whose injuries took place during military service (stateside or deployed) or during service as a first responder (Police, Fire, or EMS)
In treatment with a licensed therapist (preferred) or currently enrolled with the V.A.
Willing to submit to a criminal background check
Committed to taking the steps necessary to take charge of your life and future
□ APPLICATION INFORMATION pages 3-9
□ PHOTOGRAPHY AUTHORIZATION AND RELEASE page 10
Complete ,sign and return to Wolfhounds Legacy Assistant Dogs by U.S. Mail.
Applications will not be accepted by email for privacy reasons.
□ DD214
Please request a certified copy of your DD Form 214 from www.archives.gov/veterans/military-service-records and have it mailed directly to Wolfhounds Legacy Assistant Dogs.
□ AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
AND MEDICAL INFORMATION
Sign Provider’s Release (Authorization to Disclose Health Information) (Authorization to Disclose Health Information and Medical Information) to your Provider(s) to complete
□ FAMILY QUESTIONNAIRE
Have a family member complete, sign and mail directly to Wolfhounds Legacy Assistant Dogs. Applications will be accepted only via U.S. mail to 229 NW 22nd Place Cape Coral Florida 33993 Applications WILL NOT be accepted via email for privacy reasons.
Application Process
Wolfhounds Legacy Assistant Dogs
229 NW 22Nd Pl
Cape Coral, Florida 33993
Once the application is complete it must be reviewed by the Application Committee for tentative approval. The timeframe between tentative approval and actual receipt of a service dog can be up to two months or more. It is important to send in all required documents so that the Application Committee can make an informed decision about the application. The veteran will be notified by a representative of Wolfhounds Legacy Assistant Dogs as to the status of the application (put into the queue, deferred, etc.).
VETERAN
Service Dog Program Application
Applicant Information
Please note: Application must be completed by the veteran or answered under the direction of the veteran. If completed by someone other than the veteran, on a separate piece of paper, please identify the person completing the application and explain why the veteran is unable to complete the application on their own.
General Information
No Applications will be accepted only via U.S. mail to 407 Beltline Rd. #352, Collinsville, IL 62234. Applications WILL NOT be accepted via email for privacy reasons. 8
All participants shall be familiar with, and comply with, the regulations implementing the Americans with Disabilities Act (ADA) for Title II and Title III, dated September 15, 2010 regarding the use of a service dog. ADA guidelines can be found online at www.ada.gov. Failure to do so could result in the loss of your service dog after graduation.
By signing this application, the veteran is granting permission for Wolfhounds Legacy Assistant Dogsstaff to communicate with individuals designated in this application as medical or family.
I have disclosed all information to the best of my knowledge. I understand that failure to disclose, or providing false response, shall be grounds for automatic disqualification from consideration for, or expulsion from, the program.
If the applicant is a minor, or under guardianship or conservatorship, or a ward of the court, the parent or duly authorized representative is required to sign below pursuant to state and federal law.
Please mail the completed application form to:
229 NE 22nd Place
Cape Coral Florida 33993
PHOTOGRAPHY AUTHORIZATION AND RELEASE
I consent to being photographed/videoed by Wolfhounds Legacy Assistant Dogs, and/or it’s designee in connection with the training, promotion, marketing and educational endeavors of Wolfhounds Legacy Assistant Dogs , and/or its designee.
I understand that such photographs/videos may be published in any print, visual or electronic media, including, but not limited to, marketing materials, brochures, pamphlets, videos, website, social media, medical journals and textbooks, for the purpose of informing the medical profession, service dog training profession and/or the general public about service dog training methods for veterans with disabilities.
I understand that the photographs may portray features which will make my identity recognizable.
I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will not have any effect on any actions taken prior to my revocation. If I do not revoke this authorization, it will automatically expire ten years from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the services I receive from Wolfhounds Legacy Assistant Dogs.
I release and discharge Wolfhounds Legacy Assistant Dogs and all parties acting under their direction and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publications, including any claim for payment in connection with distribution, licensing or publication or reprinting of the photographs.
Mail the completed form to:
ATTN: Applications
229 NW 22nd Place
Cape Coral. Florida 33993
I have read this Authorization and Release and have had an opportunity to consult legal counsel with respect to this. By placing my signature below, I fully consent to the terms and conditions contained herein. This consent is a voluntary contribution in the interest of public education and I certify that I have read the above Authorization and Release and fully understand its terms.
Authorization To Disclose Health Information
(patient/applicant) (provider)
to furnish the following medical information to: Wolfhounds Legacy Assistant Dogs , 229 NW 22nd Place Cape Coral Florida 33993.
Purpose of Disclosure: Wolfhounds Legacy Assistant Dogs trains PTSD service dogs to identify early signs and symptoms related to emotional states that are occurring and provide notice to the veteran. Detailed information about symptoms and unwanted behaviors allows for more precise and effective training. In order to provide highly trained service dogs to veterans suffering from PTSD, Wolfhounds Legacy Assistant Dogs requires all applicants actively participate in therapy and/or counseling. In order for Wolfhounds Legacy Assistant Dogs to provide specialized dogs, we need detailed information about the veteran’s ongoing treatment programs and his/her responses to that treatment.
Patient’s name:
Date of birth:
Dates of treatment:
13
By initialing below, I specifically authorize the release of my mental health, developmental disabilities, alcohol/substance abuse and HIV/AIDS information:
(veteran’s initials)
I understand that:
I agree that a photocopy of this authorization is as valid as the original.
A signed release expires in one year unless the person signing the release selects to limit the period to something less than a year. This space is for the person to select how long they want to give permission for their information to be shared.
Please release the requested medical information regarding my condition to Wolfhounds Legacy Assistant Dogs. This information will be used to help the organization determine my eligibility to obtain a service dog
Please list all current medications and dosage, including medical marijuana, the patient is currently taking:
Please rate each of the following using these number descriptions:
0 = not applicable 1= mild 2 = moderate 3 = severe Motor Impairments
Sensory Impairments
Cognitive Impairments
Communication Impairments
Weakness
Vision
Attention
Comprehension
Spasticity
Hearing
Memory
Expression
Coordination
Loss of Sensation
Problem Solving
Speech
Other
Judgement
