Application Request Form

For a Service Dog, your CHILD meet MUST these criteria:

CHILD with Autism between the ages of 2 and 8 at the time of application Family must reside in Canada (regional restrictions may apply) Minimum of one parent must be able to attend team training in Cambridge

For a Companion Dog, your CHILD meet MUST these criteria:

CHILD with a disability between the ages of 2 & 18 at time of application Family must reside within a 1 hour drive of Cambridge, Ontario, Canada.

Applicant's Name:
Parents Name: (if applicant is a minor)
Applicant's date of birth:	/ / (dd)   (mmm)  (yyyy)
Address:
City:
Province:	Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québac Saskatchewan Yukon
Postal Code:
Phone Number:
Email:
Please describe your child's disability:
Describe the effect the disability has had on your life. How will a dog help?

*The information collected here is confidential and for NSD staff only*