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sUPPORT DOG
APPLICATION
The Kara Lynn Foundation will have one Support Dog available at the beginning of December. Please submit your application below. Decisions will be made by December 1.
Application
To apply, please take the time to fill out the information below
First Name of Child
Last Name of Child
Phone
Child's Date of Birth
Address
Email
Type of Epilepsy or nurological disorder diagnosed:
The support dogs are provided as puppies and will need to be trained for specific service. The cost of training is provided by Kara Lynn Foundation. Do you feel you have the time commitment to participate in the training of the support dog to meet your specific needs. Please type YES or NO
Please describe what it would mean to you to be provided a support dog (filled out by the participant)
If Participant is under 18, parents/guardians please describe what a support dog would mean to you:
Please list all family members and ages of those who live in your home.
Do you have other animals in the home? Type YES or NO If YES, Have those animals had experience around puppies/dogs
Do you Rent or Own your own home? TYPE YES OR NO If you rent, would you be able to provide a letter from your landlord stating you are allowed to have a dog in the residence? *** Please note the cost of security deposit (if applicable) for the dog would be your responsibility.
MEDIA CONSENT: I give my consent for Kara Lynn Foundation to share photos and/or videos related to receiving a support dog. I understand these images may be used by the sponsoring organizations website, social media or other marketing materials. Please sign your name that you are in agreement.
Upload File
Upload Supporting documentation for Diagnosis
Upload supported file (Max 15MB)
Submit
Thank You
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