Service Dog Application Part A

Paws for Life USA Application A 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

Social Security Number

Full Name

Date of Birth

Age

Weight

Height

Sex

MaleFemaleOption 3

Home Phone

Mobile Phone

Work Phone

Email

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Employer

Drivers License Number

Name, Address and Phone number of Nearest Relative

MILITARY PERSONNEL ONLY:

Do you have a Military Affiliation?

What Branch?

Are you Active or Retired?

Male or Female

MaleFemale

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

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.Service Dog- Third Party

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

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.Skilled Companion Dog - Third Party

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 WheelchairPower WheelchairBoth Manual & Power WheelchairCrutchesCane3-Wheel Electric ScooterSip and PuffOther

Which of the following do you do most often:

Do you Drive?Take a Bus?Do you take a Cab or Uber?Other

Describe your physical strengths and abilities. From 1-10. (Write a number from 1-10 in the space for each limb.) 1 being NO USE--------- 10 being FULL USE

Left Hand Strength from 1-10

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) Write the number between 1-10 in the space provided.

Your Speech

Easily Understandable

Tone Variation

Volume

Do you use a word board?

YesNoOther

Your Vision: Do you use corrective lenses?

YesNoOther

Do you need?

Large FontAudio TapeNote TakerOther

Your Learning Ability: and if you need assistance please explain.

Your Hearing?

Do you use?

Hearing AidASL

How do you handle the following?

Routine Medications