Service Dog Application Part A

Service Dog Application - Start Here

Please review the application instructions before completing this form. Your application will be reviewed and a meeting scheduled when all information has been received. Part A - Client Application, completed by client, Part C a Video of your home and environment (still photos are fine if providing a video is difficult), two letters of recommendation and a $25.00 application fee. Additional paperwork will be required to be completed for specific disabilities. Part B - Medical Form, completed by your physician or therapist, describing your disability. Paws for Life USA will keep your entire application confidential. Your video and written application will become the property of Paws for Life USA.

Date(Required)

Name(Required)

First Last

Social Security Number(Required)

Date of Birth(Required)

Age(Required)

Gender

Male

Female

Other

Weight

Height

Home Phone

Mobile Phone(Required)

Work Phone

Email Address(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Driver's License Number

Name of Nearest Relative(Required)

First Last

Address of Nearest Relative

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number of Nearest Relative

Do you have a Military Affiliation?(Required)

Yes

What branch?

Are you Active or Retired?

Active

Retired

N/A

How did you Hear About Paws for Life USA?

List the type of dog that would be best for your current situation from the list below:

Service Dog

A service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access. A service dog can be placed with a client that is at least 16 years of age or older and is capable of handling the dog in public without assistance.

Service Dog- Third Party

A 3rd party service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access providing that a parent or guardian is with the client at all times when in public. Third party service dogs are available to clients that are under the age of 16 or unable to handle a dog in public without assistance from a guardian or care giver.

Skilled Companion Dog

A skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. The dog is not granted public access and is trained to assist the client only in the home.

Skilled Companion Dog- Third Party

A 3rd party skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. The dog is not granted public access and is trained to assist the client only in the home. A third party skilled companion dog is available to clients that are under the age of 16 or unable to handle a dog in the home without assistance from a guardian or care giver.

What is your disability?

A disability is any condition which makes it more difficult for a person to do certain activities or interact with the world around them. These conditions, or impairments, may be cognitive, developmental, intellectual, mental, physical, sensory, or a combination of multiple factors. Paws For Life USA service dogs, are custom trained to alert and assist people with their disabilities. We help those with Autism, Brain Injuries, Diabetes, Epilepsy, Hearing, Medical, Mental, Mobility, Neurological, Physical, Psychiatric, PTSD, Seizures, Vertigo and Visual impairments. Paws For Life USA trains Assistance dogs for in home use only, therefore not granted the full public access as is given for Service Dogs. We custom train dogs for all ages based on the individual and / or their care givers ability to work with the dog.

How long have you been disabled?

If disability was caused by injury, what progress has been made post injury?

Please indicate the devices that you use:

Manual Wheelchair

Power Wheelchair

Both Manual and Power Wheelchair

Crutches

Cane

3-Wheel Electric Scooter

Sip and Puff

Other

Which transportation mode do you use most often?

Do you Drive?

Take a Bus?

Uber or Take a Cab?

Other

Describe your physical strengths and abilities from 1-10. (1 = No Use. 10 = Full Use.)

Left Hand Strength

Left Dexterity

Left Arm Strength

Left Upper Body Strength

Left Leg Control

Left Leg Strength

Right Hand Strength

Right Dexterity

Right Arm Strength

Right Upper Body Strength

Right Leg Control

Right Leg Strength

Please rate: (On a scale of 1 = Poor to 10 = Normal)

Your Speech

Easily Understandable

Tone Variation

Volume

Do you use a word board?

Yes

Other

Your Vision: Do you use corrective lenses?

Yes

Other

Do you need?

Large Font

Audio Tape

Note Taker

Other

Your Learning Ability: If you need assistance please explain.

Your Hearing?

Do you use:

Hearing Aid

ASL

How do you handle the following:

Routine Medications

By Yourself

Assisted

Provided by Others

Your Finances and Checkbook

By Yourself

Assisted

Provided by Others

Housecleaning

By Yourself

Assisted

Provided by Others

Meals

By Yourself

Assisted

Provided by Others

Getting Dressed

By Yourself

Assisted

Provided by Others

Shopping/Groceries

By Yourself

Assisted

Provided by Others

Personal Care

By Yourself

Assisted

Provided by Others

What personal attendants (including family members) do you use?

Describe how many attendants and how often? (Daily, weekly?)

Please describe your limitations.

(Mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, your ability to read and understand written material, and anything that might help us understand your needs.)

What work, school, or rehabilitation program(s) have you completed?

What is your current work or school schedule?

What are your plans for work or school?

List the people living in your home, including their ages and their relationship to you.

Do any other members of your household have a physical or mental disability?

Yes

If so, how are they disabled and what are their limitations?

Please describe your home and yard.

Is your yard fenced? If so how high?

What pets do you have now? Describe type and age.

Veterinarian’s name and phone number:

If you have an animal now, would you be willing to give up your present animal, if it cannot get along with a PFL USA dog?

Yes

Explain Reason:

If your present dog is not well-mannered, are you willing to have PFL USA train your dog in unison with your PFL USA dog?

Yes

Explain Reason:

What dogs have you had before? Describe what kind and how old you were.

On a daily basis, how will you handle walking, cleaning up after, feeding, medicating, exercising, grooming, and medical care for your PFL USA dog?

How will you handle the care of your PFL USA dog if you are hospitalized?

Will it be difficult for you to to attend group classes at the PFL USA Training Center in Marietta, GA for an hour to hour and a half one day a week for as long as needed?

Yes

Will it be difficult for you to limit your calendar for the 30-day bonding period?

Yes

Will it be difficult for you to attend one-on-one obedience | task training classes?

Yes

If you answered yes to any of the above questions, Please Explain:

Is there a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years.

Yes

If not, Please Explain:

Do you agree that this PFL USA dog will spend most of their time with their handler at home AND at work, at school, and social events if he/she is certified for public access and that no Paws for Life USA dog will be left in a yard unattended.

Yes

Paws for Life USA recommends Service Dogs NOT be crated.

If not, Please Explain:

Do you agree that a PFL USA Dog is not a family pet – he or she has a specific function in their handler’s life and minimal interaction with others except when given the free time command.

Yes

If not, Please Explain:

Do you agree that you and your dog are ambassadors for Paws for Life USA, as well as for the entire service dog industry and you will be expected to maintain your dog’s appearance and manners, as well as your handling skills.

Yes

That a PFL USA dog cannot be allowed off leash except to perform a specific task for their handler. Exercise and elimination must be done on leash.

Yes

If not, Please Explain:

You agree that you must assume full responsibility as caretaker of your PFL USA dog. You are in charge of their safety, health, and welfare.

Medical care – all care prescribed by your veterinarian and routine annual care as directed by PFL USA.

Yes

Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight.

Yes

Daily exercise and play.

Yes

You assume full responsibility for maintaining appropriate training and behavior, updating your public access certification & Community Canine certification bi -annually with Paws For Life USA. You must maintain identification for public access.

Yes

You must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage caused by your dog.

Yes

Name

First Last

Date

Time

File

Max. file size: 32 MB.

File

Max. file size: 32 MB.

File

Max. file size: 32 MB.

Return Part A of the Client Application by hitting Submit below OR print and send with your Part B & C to: Paws for Life USA P.O. Box 72016, Marietta, GA 30007-2016 If you have questions, call us at (770) 402-0297

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