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Service Dog Application Part A
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Service Dog Application Part A
Service Dog Application Part A
Paws for Life USA
2021-01-30T18:27:28-05:00
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
Male
Female
Option 3
Home Phone
Mobile Phone
Work Phone
Email
Address
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
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
Male
Female
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 Wheelchair
Power Wheelchair
Both Manual & Power Wheelchair
Crutches
Cane
3-Wheel Electric Scooter
Sip and Puff
Other
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?
Yes
No
Other
Your Vision: Do you use corrective lenses?
Yes
No
Other
Do you need?
Large Font
Audio Tape
Note Taker
Other
Your Learning Ability: and 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 & Checkbook
BY Yourself
Assisted
Provided by Others
House cleaning
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?
Personal Care Aid
Cooking
Cleaning
Medical
Other
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
No
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
No
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
No
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
No
Will it be difficult for you to limit your calendar for the 30-day bonding period?
Yes
No
Will it be difficult for you to attend one on one obedience | task training classes?
Yes
No
Please explain .
That there is 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
No
If no please explain
That an 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.
Paws for Life USA recommends Service Dogs NOT be crated.
Yes
No
If no please explain
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
No
If no please explain
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
No
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
No
If no Please explain
That you must assume full responsibility as caretaker of your PFL USA dog, 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
No
Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight.
Yes
No
Daily exercise and play
Yes
No
That 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
No
That you must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage caused by your dog.
Yes
No
Sign below if you agree to the conditions listed above. Attach additional sheets if needed to explain any ‘No’ answer.
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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