Language
English (US)
Español
Service Dog Application
Please complete all information to the best of your knowledge. Due to high volume of applications being submitted, please expect approximately 1-2 weeks to be reviewed.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Age of the applicant
*
Height of the applicant
*
Approximate weight of applicant
*
List any tasks you would like a Service Dog to assist with:
*
Are you a first responder?
Are you a Veteran?
List the applicant’s primary medical care provider who most often treats the individual. This may be a psychiatrist, psychologist, counselor, or therapist, along with the email and physical address of the provider.
*
Medical Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you been clinically diagnosed with Post Traumatic Stress Disorder (PTSD)?
*
Yes
No
Do you currently have, or ever have had, suicidal idealogy?
*
Yes
No
Has the disabled party attempted suicide in the past?
*
Yes
No
LIFESTYLE INFORMATION
What does your average day look like?
*
On average, how many times per week do you have public outings?
*
Are you able to go to public outings alone?
*
Yes
No
If they require the accompaniment of another individual when entering public situations, do they feel comfortable with that friend or family member by their side? Please explain.
*
What are some typical outings and activities you like to do?
*
Are you currently employed?
*
Yes
No
HOUSEHOLD ENVIRONMENT
Please provide the names and age of all family members that reside in your home.
*
Has anyone in the home been convicted of a felony?
*
Yes
No
List any disabilities, including psychiatric disabilities, of residents living within the same household, and the relationship of the disabled parties.
*
Will the disabled party or handler be able to provide financially for the needs of the Service Dog for the next 12 years?
*
Yes
No
List any other pets in the home, including species, breed/mix, age, and gender.
*
AGREEMENTS
Will the disabled party, and a friend or family member, be able to travel to our facility for handler training?
*
Yes
No
Handler training lasts up to 2 hours every day for up to 2 weeks. These sessions take place in public places such as parks, shopping malls, restaurants, etc. to practice training in real-life situations with various distractions and stimulus. Training can be physically draining and requires patience while learning to work as a team with the Service Dog. It takes practice and dedication on the part of the handler to reinforce the training the dog already knows, to transfer tasks from the trainer to the new handler. Please list any problems the you may experience with handler training:
*
By submitting this application I hereby acknowledge and understand that Urban Paws Service Dogs reserves the right to deny service to an applicant for any reason, including, but not limited to, failure to meet the requirements for receiving a service dog. I agree to hold free from any and all liability Urban Paws Service Dogs and its members and officers. My family, members of my household, and myself wave the rights and claims for damages and injuries, which may come from my connection and participation with Urban Paws Service Dogs.
*
Yes, I understand and agree to all of the above.
I understand that there is a $50 application fee
*
Yes
No
By typing your name below, you agree that you are a legal adult submitting an application for yourself, or that you are the parent/guardian of the disabled party who is either a minor, or deemed as legally incompetent.
*
Signature
*
Save
Continue
Continue
Should be Empty: