Dear
Veteran,
Thank you for your interest in applying
for one of our Service Dogs. Once you
have completed this application, please
double check to see that you have
answered every question completely. The
more information you can provide us the
better we can assist you.
All information
provided in this application will be
kept strictly confidential.
Once we
have received your application, we will
be contacting you by mail with (2)
Personal Reference Forms and (1) or more
Applicant Medical History Forms. One
of the Applicant Medical History Forms
must serve as your referral from
a CA licensed
psychologist, psychiatrist or mental
health counselor under which you
are currently receiving treatment.
Completing
this application does not guarantee that
we will be able to match you with a
Service Dog. We will maintain
communication with you through the whole
application process. However, should we
feel at any point in the process that we
cannot help you with one of our dogs, we
will explain our decision in writing by
registered US mail.
A Service
Dog can be a wonderful choice for many
veterans and we thank you for allowing
us to be able to serve you as you have
served us.
The Sam Simon Foundation Assistance Dogs
Program
Service Dogs for Veterans
30765 Pacific Coast Hwy #113
Malibu, CA 90265
(310) 457-5898, Office
(310) 457-9312, Fax
info@samsimonfoundation.org
www.samsimonfoundation.org
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