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Facility Animal Application

PFLUSA will keep your entire application confidential.

A facility dog is a specially trained dog that works with a professional in a variety of work locations, schools, professional offices etc. The dog must be trained to do specific, skilled tasks in a variety of different situations within the facility environment with multiple clients; the dog must be more than just a presence within the facility.

OUR FACILITY DOGS CAN HELP VULNERABLE POPULATIONS IN THE FOLLOWING TYPES OF FACILITIES:

• Schools/classrooms for special needs children, handled generally by a special needs teacher or school psychologist.


• Victim advocate centers & court houses helping victims of crime through the painful and challenging experience of a criminal trial.


• Hospitals & Physical Therapy Centers helping patients through their rehabilitation, the dogs are often handled by the physical therapists, psychologists or psychiatrists.


• Residential centers for individual with disabilities. Helping through difficult times that can include in-patient treatment or end of life care.

MINIMUM CRITERIA TO APPLY FOR A FACILITY DOG:

• Applicant must have appropriate authorization from the facility and/or corporation, district, etc. to receive a facility dog.


• Applicant is employed or a full- time volunteer at the facility.


• Applicant is the primary handler that provides goal directed interventions which promote improvement of physical, social, emotional and cognitive abilities.


• Be able to independently complete a hands-on training course and participate in refresher courses.


• Be prepared to share detailed information that pertains to their ability to meet requirements to receive a facility dog including personal history and references.


• Ability to provide a safe, loving, healthy and stable home for a facility dog.


• Ability to provide for the dog’s physical, psychological and financial needs

Please review the application instructions before completing this form. Your application will be reviewed and an interview scheduled when all information has been received.

Application

General Information, Facility, Facility Population, Conditions, Use, Care, General, Handler

Multi-line address
Multi-line address
What type of building(s) is the Facility located in?
Is there a dog relief area?
Yes
No
Is there a fenced in area for the dog to play/exercise?
Yes
No
Will the dog be on leash or off leash in the facility?
On Leash
Off Leash
Is there an area for the facility dog to rest during the workday?
Yes
No
Multi-line address
Gender
Male
Female
Birthday
Month
Day
Year
Have you owned a dog?
Yes
No
Do you have a breed or gender in mind?
Yes
No
Energy Level?
High
Medium
Moderate
Mellow
Are you willing and able to take responsibility for this dog for the next 10 plus years?
Yes
No
Do you consent to a home visit?
Yes
No
Are there other animals in your home?
Yes
No

Emergency Contact

Address of Contact

Military Personnel Only


Proof of health and vaccinations from a veterinarian will be required.

Facility Population that will interact with the dog, please check all that apply.
Facility Population Behavioral or Medical Conditions, please check all that apply.
Will the Facility Dog be interactive with clients / residents/ residents unsupervised with clients?
Yes
No
Is there a possibility that the Facility Dog could be injured by a client / resident / resident outburst /child / or are there any other threats that the dog could encounter?
Yes
No
Group Setting?
Yes
No
One on One Counseling?
Yes
No
Medical?
Yes
No
Prison?
Yes
No
Office?
Yes
No
Federal?
Yes
No

Letters of Recommendation

Please list the name and contact information of two people who will provide letters of recommendation for you.

1) Personal (not a relative),

2) professional (therapist, doctor).


Please send letters of recommendation to:


Paws For Life USA

P.O. Box 72016

Marietta GA 30007-2016

Fax 770-579-8289

Admin@pawsforlifeusa.org

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