Disability Assistance Registration

Email

First Name (required)

Last Name (required)

Phone (required)

Address (required)

City/Town (required)

Post Code (required)

As a small charity it is vital to us that we are able to keep you up to date on our work and activities by sending you occasional emails about our work, events, appeals and fundraising. Please tick to allow us to do this

Yes I am happy to receive this

Do you have a confirmed physical disability? (If accepted on to the programme we will need to request a medical report from your GP/Hospital Consultant) (required)

Yes

What is your diagnosed medical condition or disability (please note we do not train emotional support dogs) (required)

Are you over the age of 16? (required)

Yes

Can you commit to travelling to our centre in Sheffield for training appointments (required)

Yes

Have you had your current pet dog for at least 6 months? (required)

Yes

What is the name of your dog? (required)

What breed is your dog? (required)

Please state date of birth of your dog? If you do not know this please state its age in year and months (it must be between 1 and 3 years of age) (required)

Is your dog neutered?

YesNo

Where did you get your dog from and how long have you had them? (required)

What practical support would you like your dog to help you with? (required)

How would you describe your ethnicity? (optional)

Who currently provides care for you? tick as many relevant (optional)

Self carePartnerChildrenParentPaid external carerOther

How would you describe your ethnicity? (optional - We are ask this question to collect data to ensure we are doing our best to help all communities in the UK)