4 Paws for Ability | Facility Dog Application

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Fields marked with an asterisk (*) are required.

Facility Dog Application

This application is for those in need of a facility Dog. Please carefully fill out this application, only fully completed applications with submitted health forms and reference letters will be processed. Upon receiving your application you will receive an email receipt with links for the additional needed forms! This email will be going to the email provided in the first section of the application.

Once all components of an application have been received, the application will be processed. Upon acceptance the handler(s) is required to meet a fee for service to 4 Paws. Most individuals meet the contribution requirement through fundraising. After you have reached your fee for service, you will be placed in a spot in the next open placement training class to receive your service dog. Currently the wait time ranges between 2-2.5 years until we have open classes.

Client Information

Name of Facility:

Street Address

City

State: (please use 2 letter abbreviation)

Zip Code

Primary Phone

Secondary Phone

Email (This will be referred to as your On File Email Address in the future)

Emergency Contact Information

Emergency Contact Name

Emergency Contact's Phone

Alternate Emergency Contact Name

Alternate Emergency Contact's Phone

Diagnosis

What population do you work with?

What tasks do you think a service dog could do to make your clients more independent?

What are some of the primary medical conditions of your clients?

How does this affect your client's daily living skills? What are your client's limitations?

What types of adaptive equipment do your clients use? (ie. Wheelchair, crutches, hearing aid)

Service Dog Information

4 Paws for Ability requires that families maintain a high level of care with their service dog. It is expected that your dog will be fully up to date on all medical care, provided a high quality diet, maintain a healthy weight and be properly groomed. To accomplish this expectation requires a family to be prepared for a cost around $2,000-3,000 each year.

Are you financially able to care for dog?

Other No Yes

This field is required

Can you physically bathe and groom the dog?

If not, can you afford to pay grooming?

No Yes

This field is required

Please explain the financial situation if you answered "no" or "other" above

Service Dog Handling

Do you have a handler in mind for the facility dog?

No Yes

This field is required

Handler's Name

Handler's Phone Number

Handler's Address

Anything else you want us to know?

I understand that upon acceptance into the 4 Paws for Ability program, I will need to meet my fee for service which is my contribution towards the cost of the breeding, raising, training and placing of the service dog.

No Yes

This field is required

I understand that after I have met my fee for service, I will be placed in the next open placement training class which can be at least 2-2.5 years due to class availability as well as the time it will take 4 Paws to breed, raise and train my service dog.

No Yes

This field is required

I am willing to sign a contract.

No Yes

This field is required

4 Paws reserves the right to deny services to any applicant which doesn’t meet the
criteria necessary for placement of a service dog or who requires services not
trainable within the guidelines of the agency.

Contact Information:

Jennifer Lutes

jennifer@4pawsforability.org

(937)374-0385

www.4pawsforability.org

I agree that I am filling out this application to the best of my ability.

This field is required

Full Name

Today's Date

APPLICATION MUST BE ACCOMPANIED BY A $50.00 NONREFUNDABLE PROCESSING FEE. If you encounter problems when processing the fee, please immediately email MattFrederick@4pawsforability.org. Thank you!

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Adult Application Fee

$50

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If you have trouble with the payment section on the next page, please submit your application payment using the following link to ensure that your application is reviewed and sent to the next steps.

Please ensure the client's name is entered as well as the same email address used on your application. Thank you!

https://4pawsforabilitystore.org/products/client-application-fee-1

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Please contact mattfrederick@4pawsforability.org if you have questions about a form

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