Dogs With Wings Application Package Request Form

We are only able to place dogs with persons resident in the Province of Alberta.

Child or Applicant's Name:
Family or Parents Name: (if applicant is a minor)
Applicant's Date of Birth:
Address:
City:
Province:	Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code:
Phone Number:
Email:
Indicate type of Service Dog:	Service Dog Guide Dog Autism Dog Therapy Dog
Please Answer the following Questions: Please describe the applicant's (or your child's) disability: Describe the effect the disability has had on your life. How do you think a dog can help you?

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