Service Dog Application
What to do: Please complete and return the following items to Partners with Paws
• Signed Applicant Agreement • Vaccine records for current pets (if applicable) • Medical History Form: Have your physician complete and email to PwP • Professional Reference Form: Have your PT, OT, Case Worker, Psychologist or Rehab Counselor complete and mail the form to PwP
Todays Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Email
example@example.com
Household Information
Do you live in a:
House
Condo
Apartment
Duplex
Mobile Home
Please List all the members of your household, and include age and relation.
Is anyone in your household allergic to dogs?
yes
no
Please list all the current pets in your household, including their name, species/breed, sex, age, and if the are spayed or nuetered.
Please attach proof of vaccinations for all pets listed above
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Current Veterinarian
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Information
Occupation
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Typical work schedule
Please describe a typical work day
Will you be bringing your service dog to work with you?
yes
no
Education Information
If no what level of education have you completed?
Medical Information
Disability (optional)
Do you use any assistive devices? If yes please indication what kind.
Are you able to transfer on your own? If no, please describe your type of transfer.
Are you able to walk? If yes, how long/far are you able to?
How much strength do you have in your hands?
Normal
Some weakness
No Strength
Do you have any vision or hearing problems? If yes please describe:
Do you require attendant care? If yes please describe:
What form of transportation do you use?
Recreational Interests
What do you do in your free time? (ex. Hobbies, interests, social activities)
Service Dog Information
What type of service dog are you looking for?
PTSD
Diabetic
Psychiatric
Autism
Other
If other, please explain:
What tasks would you like your service dog to perform?
Autobiography
Please use the text box below to tell us about yourself. Give us a description of a typical day for you and what activities you do and the places you go. Also, please describe how your disability has affected your life and how independent you are.
Type a question
References
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you:
I,
First Name
Last Name
certify that the information provided in this(Print name) application is true and correct, AND understand and agree: 1. To give permission to Partners with Paws to verify this information through whatever reasonable means necessary. 2. That clients and dogs are matched based on a number of factors including compatibility and training requirements and not on a “first come, first served” basis. 3. That Partners with Paws will schedule a home visit. 4. That if I am accepted, I will be put on a waiting list and understand that it may take up to 3 years to be placed with a dog. 5. That being accepted does not guarantee being placed with a dog. Partners with Paws reserves the right during this process not to make a placement with any applicant who is, who is for any reason, not meeting the requirements of Partners with Paws including but not limited to managing care for the dog affectively and safely. 6. That my acceptance in the program will not be decided with race, religion, color, gender or sexual orientation. 7. That I will attend scheduled training classes with Partners with Paws to maintain the training of my dog. 8. That all the information on this application will remain confidential and property of Partners with Paws. 9. That I authorize my vet to release any information requested by Partners with Paws. 10. A Partners with Paws dog will not take responsibility for the safety of the recipient. A Partners with Paws dog does not have the ability to determine if a situation is dangerous or safe (ex. traffic, strangers)
*If the applicant is a minor, under guardianship, conservatorship or a ward of the court, the parent or guardian is required to sign below pursuant to state and federal law
Please Upload the Medical History Form below once filled out or you can print and bring it with you to your first meeting with Partners with Paws.
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Save Document and have a Physician fill it out. You can either bring the document with you to the first meeting, mail it us, or scan and email. If you are mailing, please email us first for the address.
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Application Processing Fee
$25.00
$
25.00
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First Name
Last Name
Credit Card Number
Security Code
Expiration Month
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Expiration Month
Expiration Year
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This is a nonrefundable donation fee that goes towards processing your application.
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