Application - StandWithMeOrg
Thank you
Martina DiRose
for donation of logo artwork.
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ANNUAL REPORT
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TESTING
First Name
Last Name
Are you a United States Veteran?
Yes
No
Street Address
City
State
Zip
Phone Number
Are you able to receive email communications reliably?
Yes
No
Email:
Do you have a service-related mental health disability?
Yes
No
Can you provide documentation of your disability?
Yes
No
Do you have any physical disabilities or limitations?
Yes
No
If yes, please explain:
ARE YOU CURRENTLY ENGAGED IN TREATMENT OR THERAPY FOR YOUR DIAGNOSED CONDITION?
Yes
No
One of the steps a little further along in the application process will require that you provide us a letter of recommendation from your treatment provider before you begin the program. You’ll also need to remain actively engaged with that treatment provider for the duration of the training program.
CAN YOU COMMIT TO TRAINING CLASSES, PRIVATE LESSONS, AND/OR PUBLIC SITE TRAINING SESSIONS ON A WEEKLY BASIS FOR APPROXIMATELY ONE YEAR?
Yes
No
Do you have or are you able to arrange transportation to attend training sessions?
Yes
No
Do you currently own a dog?
Yes
No
If no, would you like assistance in obtaining a dog?
Yes
No
If you already own a dog, please answer the following
Dog's Name
Dog's Age
Breed or Breed Mix
Height at Shoulders
Weight
Spayed/Neutered?
Yes
No
Up to date on vaccinations?
Yes
No
Using flea/tick prevention?
Yes
No
Have there been any incidents of aggression in your dog's past?
Yes
No
If yes, please explain:
Please select one option:
I give my permission for photos taken during the training program which may include myself and my dog to be used on the internet / social media for the purpose of helping with awareness and fundraising for future veteran/dog teams.
I prefer that any photo taken which may include myself, not be used for promotional purposes.
Demographic Data - OPTIONAL, Not required to be completed for consideration in our program.
Demographic Data for Fundraising Efforts. These statistics are requested by many of the outlets from which we request donations to operate our program. All analyses conducted on demographics will report aggregate statistical findings and will not identify individuals. This section is completely OPTIONAL.
Your Sex:*
Female
Male
Transgender
Non-binary
Other
Prefer not to say
Your Age:*
18-24
24-44
45-64
65+
Prefer not to answer
What is your marital status?
Single, never married
Married or domestic partnership
Widowed
Divorced
Separated
Prefer not to say
Your Race and Ethnicity~:*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Caucasian
Prefer not to answer
What is your total household income?
Less than $20,000
$20,000 to o$34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000+
Prefer not to say
In which branch(es) of the military did/do you serve? Please select all that apply.
Air Force
Army
Coast Guard
Marine Corps
Navy
In which component(s) did/do you service?
Active Duty
National Guard
Reserves
~Definitions for Racial and Ethnic Categories
The Revisions to OMB Directive 15 defines each racial and ethnic category as follows:
American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
The categories and definitions provide a common language to promote uniformity and comparability of data on race and ethnicity. Moreover, federal agencies have a continuing commitment to monitor the operation of its review and award processes to detect, and deal appropriately with, any instances of real or apparent inequities. All analyses conducted on race and ethnicity report aggregate statistical findings and do not identify individuals.
STAND WITH ME does not discriminate based on gender, race, ethnicity, religious affiliation, sexual orientation, or diagnosis.
STAND WITH ME requires that all participants be sober (free of influence from any genre of mind altering substance) during all training sessions. Violation of this rule will be cause for immediate dismissal from that day’s session. A second violation of this rule will be cause for immediate dismissal from the program. Re-entry into the program after a substance abuse related dismissal will require documentation from a treatment professional that you have been maintaining sobriety, and are actively addressing the issue in treatment. Using mind altering substances while you and your dog are in the community as a service dog team is unacceptable.
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