Owner Trained Assistance Dog Application

Owner Trained Assistance Dog Application

Use this form to complete the Owner Trained Assistance Dog Application packet. Answer all applicant-facing questions and provide the requested dog, medical, household, and contact information.
Applicant Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City/State/Zip
Phone - Home
Please enter a valid phone number.Format: (000) 000-0000.
Phone - Cell
Please enter a valid phone number.Format: (000) 000-0000.
Phone - Work
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Occupation
Household Members
Significant Other

First NameMiddle NameLast Name
Child 1 (Name/Age)
Child 2 (Name/Age)
Child 3 (Name/Age)
Other 1
Other 2
Pet 1 (Species/Name)
Pet 2 (Species/Name)
Residency and Medical Background
Are you a permanent resident of Portage County?
If yes, how long?
If not, which county?
Diagnosis - type of disability
Diagnosis date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Medical Concerns
What type of medical treatment are you receiving? Include medications
Physician(s)
Therapist (OT, PT, Speech, etc.)
Types of restrictions/precautions
What adaptive equipment/aids do you use?
Transportation and Program Interest
Do you drive?
If not, how do you plan to attend class?
How did you hear about PawsU?
What do you hope to gain from this program?
Dog Information
Dog's Name
Breed
Dog Size
Micro-Chip #
Micro-Chip Organization
Dog Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dog Sex
Veterinary Clinic
Primary Veterinarian

First NameMiddle NameLast Name
Vet Clinic Phone
Please enter a valid phone number.Format: (000) 000-0000.
Vet Clinic Fax
Please enter a valid phone number.Format: (000) 000-0000.
Vet Clinic Address
Vet Clinic City/State/Zip
Training and Behavior
Previous Training
Explain any behavior issues or concerns
How do you handle these situations
Signature and Office Use
Signature of applicant
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Non-Refundable Application Fee

Application Fee

Non-refundable application fee

Will be applied to the program fee upon acceptance

$100.00 Quantity

Total

Credit Card

Should be Empty:

Owner Trained Assistance Dog Application

Applicant Information

Household Members

Residency and Medical Background

Transportation and Program Interest

Dog Information

Training and Behavior

Signature and Office Use

Non-Refundable Application Fee*

Credit Card

Non-Refundable Application Fee