Membership Application

Thank you for wanting to join the AssistanceDog Council.

Please complete the following form to apply.

(NOTE: WE ARE AWARE THAT THE FORM REPEATS ITSELF A COUPLE OF TIMES, HOWEVER YOU ARE ABLE TO STILL JOIN BY ONLY COMPLETING ONE OF THE FORMS BELOW. THE FORM ENDS AT THE “EMPOWERED BY CIVICRM”  FOOTER)
 
Total Amount
New User
This should show the head and shoulders, and would ideally be on a plain background. It should be passport style, however you are able to smile
Please separate with a ,
Please separate with a ,
Do you take any medication *
Bladder/Bowel Conditions *
Hearing Impaired *
Invisible Disabilities *
Mobility Issues *
Non-Verbal *
Sight Impaired *
Please upload a copy of either DLA, PIP, Blue Badge or Drs letter stating that you are disabled as defined by the Equality Act 2010
Assistance Dog information
This should show the head and the shoulders of the Assistance Dog. The dog is preferred to be in a seated position
This should show the head and the shoulders of the Assistance Dog. The dog is preferred to be in a seated position
This field should only be updated by staff
Cleared by Vet *
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