Pawsitive Action Service Dog Application
service dog application
Name: *
Gender: *
Date of birth *
MM
/
DD
/
YYYY
Street Address *
City *
State: *
Zip Code *
email address *
Cellphone Number *
Home Phone Number
Are you 18 years of age? *
Parental Consent (if a minor)
Parent's Name
Parent's Email Address:
Parent's Cell Phone:
Home Phone Number:
Cell Number:
Do you approve?
Veteran
Are you a U.S. veteran? If so, please complete the sections 9. If not, please skip to the section titled "Personal Information."
Veteran Status
Date of Disability
What was your rank?
Medals of Honor
Is your disability a Service-Related:
Is your disability a Service-Related:
Did you receive an honorable discharge?
Define Disability (please be specific):
Cause of Disability (please be specific):
Define Specific Need for an Assistance Dog (please be specific):
Veteran Support-Primary Sponsor (Spouse/Partner/Dependent)
Name:
Phone Number:
Email:
Relationship to Veteran:
Years Known:
If there are other behaviors that are affecting you negatively, please explain below:
Veteran Documentation:
Please provide each of the following:
Primary Disability:
Personal Information
Your Doctor's Name:
Your Doctor's Contact Information:
Effects of the Disability:
Is your mobility or condition limited? If so, how?
Describe any hospitalizations you have had in the last three years
How long have you lived with your current disability/ies?
Describe your own current activity level:
Do you have a healthy support group to help you through difficult times?
What activity do you most enjoy?
Describe a typical day in your life:
What are your hopes and fears of receiving and living with an Assistance Dog? *
Are you Presently : *
Required
Have you discussed this application with your employer and/or school and are they supportive of the idea of you always having an Assistance Dog at your side? *
Have you applied with other Assistance Dog Organizations? *
Are you willing and able to attend weekly classes at our location in St. Cloud? (Required to certify you as a fully-trained Assistance Dog team) *
Are you able to financially support and provide food, shelter, water, toys, equipment and medications to the PAF Certified Assistance Dog, if selected as a recipient? *
Are you willing and able to attend required ongoing monthly classes, outings and annual exams to maintain your dog’s certification as a fully-trained Assistance Dog? *
Home Environment
I/we live in a.... *
Describe your neighborhood? (i.e. downtown, suburban, rural, busy street, etc.) *
Is your yard fenced? *
List the Individuals who live in your home (name,gender, and age) *
Do all members of your household support you having an Assistance Dog? *
Do any members of your household smoke cigarettes? *
Are there other individuals with disabilities in your home? if yes, describe: *
What time do you wake up? *
What time do you go to work? *
what time do you go to sleep? *
If you receive a PAF assistance dog, where would the dog relieve itself? *
What exercise would you provide your dog? *
List the other animals in your home (name, type/breed and age). *
Does anyone living in your house have a fear of dogs? *
Are there any individuals in your home who are allergic to dogs? *
Required
Referral
How did you learn about Pawsitive Action? *
Basic Policy & Process
Pawsitive Action was established in 2008 and began placing assistance dogs with veterans and individuals with limited abilities in 2013. Clients will remain in good standing by participating in ongoing training opportunities and successfully progressing and/or renewing their full access certification. Pawsitive Action makes no promises to the placement or selection of any individual who has applied for a PAF Assistance Dog. We work with everyone on a case-by-case basis but do not train dogs for hearing, sight or diabetic alert. Due to funding and grant restrictions, the needs of the individual applicants and the intense training required of a fully-trained assistance dog, only a limited number of PAF dogs are placed each year. Please understand and respect that Pawsitive Action is a family-friendly environment. *
Required
DRUG AND ALCOHOL: No illegal drugs are permitted on the property, nor shall those under the influence be allowed to remain on the premises. We reserve the right to remove and ban any person violating this policy. Alcohol, unless served by Pawsitive Action for some event, may not be carried on one’s body, nor consumed on site. No excess of drinking or drunkenness will be tolerated on the premises. *
In addition to this form, please submit the following via email to pawsitiveaction@gmail.com or bring a copy with you upon visiting us at 5701 Leon Tyson Rd. St. Cloud, FL 34771 for your Meet an Greet.
Electronic Signature and Date: *
Submit
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