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Alzheimer's Assitance Dog Application

This application is for individuals with Alzheimer's or other forms of dementia and who are, or are preparing to, no longer be independent. This placement is a three unit team with the primary handler being a spouse or other caregiver who lives in the home. This application can be completed by the person with Alzheimer's or by their caregiver. 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 recipient is required to contribute 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 these classes are full about 2 - 2.5 years out.

Client Personal Information

All of the contact information under the Client will be the primary way that 4 Paws contacts you regarding the application process as well as communication going forward.

Emergency Contact Information

Spouse/Caregiver's Information

What is the relationship of this person to the client?

Medical Information

Physician Information

If Applicable


Service Dog Certification

To be the handler of the service dog, the individual must be capable of making 100% correct choices for themselves and the service dog to the same capacity of an adult. Alzheimer's Assistance Dogs are placed on a three unit team (Spouse/Caregiver, Client, and Service Dog) and the Spouse/Caregiver must be present with the team in public. A service dog is not able to use higher judgement and determine things that may be "right" or "wrong" (ie. don't touch the stove if it is hot, lead a person who is confused back home, etc.) The service dog is a tool for a spouse/caregiver to use to help with task trained calming, comforting, and redirecting behaviors as well as safety measures if needed to prevent wandering through tethering out in public and/or search and rescue to lead a spouse/caregiver to the lost partner. 

Employment Information

Spouse/Caregiver's Employment Information

Household Information

Pets & Veterinary Information (Past & Present)

4 Paws for Ability requires that all pet dogs within the home are: up to date on vaccines, receive monthly heartworm medication, friendly towards other dogs, inside dogs, and that the number of dogs in the home does not exceed three dogs by the time that the service dog would be placed in the home. Applicants understand that they are agreeing to not add any additional pet dogs to the home from now until at least one year after the service dog is placed to give the service dog time to adjust and bond appropriately.

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 $1,500-2,000 each year.

Service Dog Handling

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 info:

Jennifer Lutes


$50 Nonrefundable Application Fee Due in order to submit Application $50 Nonrefundable Application Fee Due in order to submit Application
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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!