* Name, Address, & Phone number of nearest relative.
What branch of the Military do you have an affiliation with?
Are you Active or Retired?
* How did you Hear About Paws for Life USA
List the type of dog that would be best for your current situation from the list below:
A disability is any condition which makes it more difficult for a person to do certain activities or interact with the world around them. These conditions, or impairments, may be cognitive, developmental, intellectual, mental, physical, sensory, or a combination of multiple factors. Paws For Life USA service dogs, are custom trained to alert and assist people with their disabilities. We help those with Autism, Brain Injuries, Diabetes, Epilepsy, Hearing, Medical, Mental, Mobility, Neurological, Physical, Psychiatric, PTSD, Seizures, Vertigo and Visual impairments. Paws For Life USA trains Assistance dogs for in home use only, therefore not granted the full public access as is given for Service Dogs. We custom train dogs for all ages based on the individual and / or their care givers ability to work with the dog.
How long have you been disabled?
If the disability was caused by injury, what progress has been made post injury?
Please indicate the devices that you use:
Which of the following do you do most often:
Describe your physical strengths and abilities.
From 1-10. (Write a number from 1-10 in the space for each limb.)
1 being NO USE--------- 10 being FULL USE
Right Upper Body Strength
Please rate: (On a scale of 1=Poor – to – 10=Normal)
Write the number between 1-10 in the space provided.
Your Vision: Do you use corrective lenses?
Your Learning Ability? If you need learning assistance, please explain.
How do you handle the following?
Your finances & Checkbook
What personal attendants (including family members) do you use?
Please describe how many attendants you use and how often (Daily, weekly).
Please check limitations that apply to you:
Please describe anything that might help us understand your needs relating to your limitations or struggles.
What work, school, or rehabilitation program(s) have you completed?
What is your current work or school schedule?
What are your plans for work or school?
List the people living in your home, including their ages and their relationship to you.
Do any other members of your household have a physical or mental disability?
If so, how are they disabled and what are their limitations?
Please describe your home and yard
Is your yard fenced? If so how high?
What pets do you have now? Describe type and age
Veterinarian’s name and phone number
If you have an animal now, would you be willing to give up your present animal, if it cannot get along with a PFL USA dog?
If your present dog is not well-mannered, are you willing to have PFL USA train your dog in unison with your PFL USA
dog?
What dogs have you had before? Describe what kind and how old you were.
On a daily basis, how will you handle walking, cleaning up after, feeding, medicating, exercising, grooming, and medical
care for your PFL USA dog?
How will you handle the care of your PFL USA dog if you are hospitalized?
Will it be difficult for you to to attend group classes at the PFL USA Training Center in Marietta, GA for an hour to hour
and a half one day a week for as long as needed?
Will it be difficult for you to limit your calendar for the 30-day bonding period?
Will it be difficult for you to attend one on one obedience | task training classes?
Is there a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years?
Paws for Life USA recommends Service Dogs NOT be crated.
Do you agree that a PFL USA dog will spend most of their time with their handler at home AND at work, at school, and social events if
he/she is certified for public access and that no Paws for Life USA dog will be left in a yard unattended.
Do you agree that a PFL USA Dog is not a family pet – he or she has a specific function in their handler’s life and minimal interaction with others except when given the free time command?
Do you understand that you and your dog are ambassadors for Paws for Life USA, as well as for the entire service dog industry and you will be expected to maintain your dog’s appearance and manners, as well as your handling skills?
Do you agree that a PFL USA dog cannot be allowed off leash except to perform a specific task for their handler? Exercise in a secure fenced area is permitted. Elimination must be done on leash to maintain relieving on command cue.
You must assume full responsibility as caretaker of your PFL USA dog, and commit to be in charge of their safety, health, and welfare.
Medical care – all care prescribed by your veterinarian and routine annual care as directed by PFL USA. (Copies of medical records must be sent to Paws for Life USA whenever services are provided. PFL USA will provide minimum requirements for care.)
Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight.
That you assume full responsibility for maintaining appropriate training and behavior and updating your public access certification annually with Paws For Life USA. You must maintain identification for public access.
That you must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage
caused by your dog.
* APPLICANT SIGNATURE:
Sign below if you agree to the conditions listed above. Attach additional sheets if needed to explain any ‘No’ answer.Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
GUARDIAN SIGNATURE: Sign below if you agree to the conditions listed above. Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Return Part A of the Client Application by hitting Submit below OR print and send with your Part B & C to:
Paws for Life USA
P.O. Box 72016
Marietta, GA 30007-2016
If you have questions, call us at (770)-402-0297
Please enter any two digits * Example: 12