Application - Whalen's Heroes

Application for a Service Dog

Thank you for your interest in obtaining assistance in funding a Service Dog from Whalens Heroes Inc., known as WHI hereinafter. We fund the training/dog for men and women disabled in the line of duty while serving our country in the U.S. Military, who now suffer from a clinical diagnosis of PTS. WHI does not provide guide dogs to individuals who are legally blind or hearing impaired.

Due to the limited number of serviced dogs, satisfaction of all of the requirements herein does not guarantee that you will be provided with a service dog. WHI does its best to meet the needs of qualified candidates, but due to the overwhelming nature of the need it is a competitive process to be awarded the funding assistance for one of the service dogs and we, along with Ultimate Canine, see the best possible situation for the recipient and the dogs.

"*" indicates required fields

Step 1 of 7

Personal Information

Full Name of Applicant*

First Middle Last

Gender*

Male

Female

Birthday*

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Is this also your mailing address?*

Yes

If no, please provide your mailing address

Street Address Address Line 2 City State ZIP Code

Are you physically, mentally, emotionally and financially able to care for a service dog if you are awarded one?*

Yes

Start date	End date	Location	Actions

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References

Reference one's name*

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

Reference two's name*

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

Acknowledgement and Signature

Name*

By signing below, I certify that all the information I have provided on this application is current, accurate and correct and truly represents my needs and present situation. I understand that failure to give complete information or falsification or misrepresentation of information may prevent me from receiving a service dog or may cause me to lose a service dog if one is awarded to me. I understand that any information obtained by WHI is confidential and other than being shared with WHI’s agents, representatives, or advisors for the sole purpose of assessing my qualifications for a service dog, will not be released to any person or outside agency without my written consent.

First Middle Last

Today's date*

Final Checklist

To apply for funding assistance for a Service Dog from WHI, the following (copies included) are required. Please include a mark next to each item confirming you have completed that section and/or uploaded the appropriate document(s).

Checklist*

Completed Application for Service Dog

Waiver, agreeing to allow WHI to share your application with Ultimate Canine and acknowledgement to go through the qualification/matching process with Ultimate Canine.

Two references who do not live with you

Physician statement of disability/recommendation for dog (upload below)

Confirmation that your injury/diagnosis is directly related to your service/combat.

DD214 that contains a separation code (upload below)

Copy of driver's license

Upload physician statement of disability/recommendation for dog

If you do not have the documents ready to submit, you can email them to us later.

Accepted file types: doc, docx, pdf, Max. file size: 256 MB.

DD214 that contains a separation code

If you do not have the documents ready to submit, you can email them to us later.

Accepted file types: doc, docx, pdf, Max. file size: 256 MB.

Copy of driver's license

If you do not have the documents ready to submit, you can email them to us later.

Accepted file types: pdf, png, jpg, Max. file size: 256 MB.

Name*

Please sign and date acknowledging you have completed the application in full and understand the terms and conditions.

First Middle Last

Date*

Application for a Service Dog

Personal Information

Family/Living Situation

Service to our Country

Service Dog Preference

References

Acknowledgement and Signature

Final Checklist