Puppy Jake Foundation - Veteran Application of Interest

Application of Interest

Thank you for your interest in receiving a service dog from the Puppy Jake Foundation (PJF), a 501(c)(3) organization dedicated to helping military veterans through the assistance of well bred and professionally trained service dogs.

Completed and signed medical release form

At this time, we only consider Applications of Interest from qualified military veterans. This application of interest is the first step in determining whether PJF can meet your needs. Once you have completed this application, a member of our veteran coordination team will be in contact with you. If you need assistance as you are filling this out, please contact our office at (515) 639-8785 or Zac@puppyjakefoundation.org.

Before you begin, there are several items you need to submit with your Application of Interest:

Photocopy of your most recent DD214 of NGB22. This is the paperwork you should have received when you separated from the military. If you have more than one DD214, please include the most recent. If you need a copy, you may request it through the Department of Veteran Affairs.
Photocopy of your driver’s license
Doctors prescription that states a service dog would benefit your physical or mental health
A completed Mental Health Evaluation
completed by your psychiatrist, physician or therapist
Completed and signed medical release form

Or complete digitally below.

Name

DOB

Address

City, State, ZIP

Cell Phone

Work Phone

Home Phone

List all the people living in your home. Include their Name, Age, & Relationship:

Has anyone in the home been charged* with a felony?

Yes No

Has anyone in the home been charged with animal cruelty?

Yes No

Do you currently have any pets?

Yes No

If yes, please list Name, Species, Breed, Age, Spayed/Neutered, and Inside or Outside:

Describe your support system. Be sure to include your personal, social and medical team members.

Are you employed and/or attend school?

Yes No

If so, what is the name of your Employer and/or school?

Would you take your dog with you to school and/or work??

Describe your typical day. Be sure to include how often you are in public. Think about errands such as going to the post office, grocery store, VA appointments, etc.

Do you need help in public places such as restaurants, stores, or crowded areas?

Yes No

Do you need help settling down when at home?

Yes No

Do you have nightmares or flashbacks related to your service?

Yes No

Do you have memory loss?

Yes No

Do you have anxiety and/or difficulty controlling anger?

Yes No

Do you need assistance opening doors, drawers and/or picking up items?

Yes No

Do you have loss of fine motor skills, coordination problems, limited mobility or difficulty getting off the floor or out of a chair?

Yes No

Have you ever been treated for substance abuse or chemical dependency?

Yes No

If yes, when were you treated for substance abuse/chemical dependency?

In your own words, what are your biggest daily struggles? How would a dog help?

What type of dog is right for you?

Service dog: This dog goes everywhere with you – the VA, grocery stores, restaurants, vacation. Emotional Support Animal: This dog doesn’t leave the home often. It will provide skills meant to support you in the home such as assistance with anxiety and nightmares. Other - please explain

Other - explained

You must provide a copy of your DD214 to validate your military service. If you have more than one, please attach all documentation. If you do not have copies of your DD214, you can find this on your eBenefits page on the Department of Veterans Affairs, or you may request it directly from them. Please note, we do not consider veterans who have been dishonorably discharged.

Year(s) of Service

Discharge Status

Service Connection Rating

Past Deployments. Include Year(s) in country, Operation, Country, and Operating Base

Will you have any issue going through the Trupanion process (pet insurance for service dogs) through the VA?

Yes No - Note: We will walk you through this entire process and set you up for success from the very beginning to make sure you qualify for this benefit.

Is there a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8+ years?

Yes No

Have you applied to other service dog organizations?

Yes No

If yes, what organization(s) and what is the status of your application(s)? If so, what organization(s) and what is the status of your application? Failure to list this will result in application termination.

Is there anything else we should consider when reviewing your application?

Application Process and Terms

Due to the time and resources it takes to train a service dog, there may be a considerable wait from the time your Application of Interest is approved for placement with a dog. We will do our best to keep you informed of your place in line, as well as the timing. Applications of Interest are reviewed 2-3 times a year ahead of dates when veterans are matched with available dogs. Only complete applications will be considered. Step 1: Complete and submit Application of Interest Step 2: Meet by phone, Zoom video or in person with Veteran Coordination staff Step 3: If your Application of Interest is accepted, you will move to Phase 2 of the application process and be asked to complete and submit an Application for Service Dog with $250 application fee. Step 4: Interview and home visit Step 5: Placed in queue for matching Step 6: Once matched, there is a mandatory team training every second Saturday for five months at the PJF facility in Urbandale, Iowa. Following graduation from this training, there will be a follow up training for five months on the second Saturday of the month. All veterans receiving a Puppy Jake service dog must be able to attend all required training including one or more of your support team. Step 7: Annual public access training at our facility in Urbandale

Waiver

By typing my name as a digital signature below, I hereby acknowledge I have read the above terms and I understand that Puppy Jake Foundation reserves the right to deny service to an applicant for any reason including but not limited to, failure to meet the established criteria for receiving a service dog or requesting services that Puppy Jake does not provide. I do hereby agree to hold free from any and all liability Puppy Jake Foundations, its Board of Directors, Officers, Staff and Volunteers. I declare myself to be physically sound to participate with Puppy Jake. I, the applicant, waive the rights and claims for damages and/or injuries, which may come from my relationship and participation with Puppy Jake Foundation.

Digital Signature

Today's Date

Additional Files

*We will perform a background check

Please note:

If your Application of Interest is approved, you will receive the full Application for a Service Dog. Along with required paperwork, a $250 application fee will be required. This fee is the only funding we require. It demonstrates that you understand the seriousness of undertaking a service animal. If you cannot afford the application fee, assistance may be available.

At all times, applications are reviewed with a commitment to equality, diversity and inclusion to ensure fairness without regard to sex, sexual orientation, race, ethnicity, national origin, age, religion or any other legally protected classifications.

The Puppy Jake Foundation is committed to full accessibility for individuals applying for or interested in learning more about the services we provide. We work continuously to increase the accessibility and usability of our website, applications, documents and materials related to applicants and existing Veteran/Dog teams as well as members of the Board of Directors, staff and volunteers. For assistance with accessing our website, applications, documents and materials, please contact Veteran Coordinator, 3101 104th Street, Urbandale, IA 50322, call (515) 639-8785 or email Zac@puppyjakefoundation.org.