4 Paws for Ability | Child Client Application

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Child Client Application

This application is for both children under 18 and individuals who are older but not their own legal guardian. The majority of 4 Paws placements operate as a 3 unit team (parent/handler, child/partner and service dog), with the handler using the service dog as a tool to assist the partner. 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!

Once all components of an application have been received, the application will be processed. Upon acceptance, the handler(s) is required to met their fee for service which goes toward the mission of 4 Paws. Most families 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.

Child Information

Child's First Name

Child's Last Name

Child's Date of Birth

Street Address

City

State

Zip Code

Primary Phone Number

Secondary Phone

Email Address: This email address will be listed as your primary email address and will be referred to as your On File Email Address in the future

Please explain custody and legal guardianship of the child:(Examples: 1. Both parents live in the same household as the child, 2. I am the child's grandmother and have legal custody, 3. Parents are divorced, but we have shared custody, 4. I am a single mother and have sole custody.)

Parent/Legal Guardian Information

Applicant Alternate Street Address (If Needed)

Applicant Alternate City (If Needed)

Applicant Alternate State (2 letter abbreviation) (If Needed)

Applicant Alternate Zip Code (If Needed)

What is your relationship to the child?

Legal Guardian Father Mother

This field is required

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Email Address

Parent/Guardian 1 Primary Phone

Parent/Guardian 1 Secondary Phone

What is your relationship to the child?

Legal Guardian Father Mother

This field is required

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Email Address

Parent/Guardian 2 Primary Phone

Parent/Guardian 2 Secondary Phone

Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Phone

Alternate Emergency Contact's Name

Alternate Emergency Contact's Phone

Medical Information

What is the Child's primary diagnosis?

What tasks do you think a service dog could do to assist your child?

Does the child want a service dog? Why? (Preferably in the child's own words.)

What are the thoughts of the rest of the family and what do they think would be the benefits of a service dog?

What other medical conditions does the Child have?

How does this affect their daily living skills? What are their current limitations?

Do they have any restrictions or precautions as a result of their diagnosis?

What type of medical treatment are they currently receiving?

What medications are they currently taking and what are they each for? Please list.

What types of adaptive equipment do they use? (ie. wheelchair, crutches, hearing aid)

Physician Information

May we contact the physician?

No Yes

This field is required

Physician's Name

Physician's Mailing Address

Physician's City

Physician's State (2 letter abbreviation)

Physician's Zip Code

Physician's Phone

If Applicable:

May we contact the individuals listed below?

No Yes

This field is required

Physical Therapist's Name

Physical Therapist's Phone

Physical Therapist's Email

Occupational Therapist's Name

Occupational Therapist's Phone

Occupational Therapist's Email

Mental Health Professional's Name

examples: licensed social worker, psychologist, psychiatrist, therapist, counselor, mental health nurse practitioner, school counselor, behaviorist, or registered behavior technician.

Mental Health Professional's Phone

Mental Health Professional's Email

Service Dog Certification

Three Unit Team: Most 4 Paws placements are with children needing support, and 4 Paws has developed a three unit team (Parent/Handler, Child and Service Dog) to meet their needs. This is the case for all situations where a child may be affected cognitively, behaviorally or intellectually. The Parent/Handler must be present with the child in public and will be the one handling the service dog for the benefit of the partner.

Two Unit Team: 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. A two unit team certification is given when the child has fully shown complete ability to make correct choices in public for themselves and the service dog as displayed in the Placement Training Class. The youngest that this will typically be considered is 12 years old.

Which certification do expect to receive?

Two Unit Team Three Unit Team

This field is required

What type of service dog are you seeking?

Please visit our website at www.4pawsforability.org to identify the right type of service dog you need.

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.

Are you financially prepared to care for a service dog (required)?

Other No Yes

This field is required

Are you financially prepared to feed the dog (about $60-$75/month)?

No Yes

This field is required

Are you physically able to bathe and groom the dog?

No Yes

This field is required

If no, are you financially prepared to pay for grooming?

No Yes

This field is required

Please explain the financial situation if you answered "no" or "other" to any of the above.

Will you need financial help with vet care?

No Yes

This field is required

How many years do you expect to care for the dog?

Who will handle the service dog in public?

Who will handle the service dog in the home?

Please list all potential handlers of the service dog

Employment Information

Are you currently employed?

No Yes

This field is required

Employer

Employer's Address

Employer's City

Employer's State (2 letter abbreviation)

Employer's Phone

Household Information

Type of Home

Other House Apartment

This field is required

If other, please describe

Do you own or rent your home?

Rent Own

This field is required

If you rent, please list your Landlord's name.

If you rent, Landlord's Phone

Do you have a fenced yard?

Partial No Yes

This field is required

If your yard in not currently fully fenced, is this something you plan to do?

No Yes

This field is required

If you will not have fence, do you have access to a fully fenced in area where you could exercise a dog?

No Yes

This field is required

Please describe how you will provide exercise for the dog:

Please List everyone who resides in the home, including their Name, Age, and Relationship:

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 within 6 months before and after receiving the service dog.

Are there currently pets within in the home?

No Yes

This field is required

Please list all pets that live in the home, including their Species, Name, Age, Sex, and whether they are spayed or neutered.

Do they live inside?

No Yes

This field is required

If no, where do the outdoor pets reside?

Are they up to date on all vaccines?

N/A No Yes

This field is required

If not all pets are up to date on vaccinations, please explain why

If you currently have a dog, is it on heartworm preventatives?

If your current dog is not on heartworm preventatives, please explain why

Please list past pets and why you no longer have them: (If they have passed away, please include age and cause of death. If they were rehomed, please include reason)

Veterinarian Practice Name

Veterinarian's Name

Veterinarian's Phone

How long have you used this veterinarian?

Demographic

4 Paws for Ability does not discriminate based on any demographic information provided. The voluntary completion of this information supports the ability of 4 Paws to seek funding from grants and other sources that require demographic information to measure outcomes.

Veteran/Member of the Military in the Immediate Family:

First Responder in the Immediate Family:

Gender of Applicant:

Race and Ethnicity of Applicant:

Household Income

Household Size

Additional Information

Is there anything else you would like us to know?

The total cost of breeding, raising, and training a service dog is between $40,000 -$60,000. Clients are only asked to contribute a portion of that cost. Click here for our current fee for service I understand that upon acceptance into the 4 Paws for Ability program, I will need to meet my fee for service. 4 Paws reserves the right to use non identifying applicant information for fundraising purposes to raise the remaining funds needed to place the service dog. Information may include, first name, disability and state.

I agree to the statement above

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 to receive my service 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.

I agree to the statement above

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 info: Clientservices@4pawsforability.org, (937)374-0385, or www.4pawsforability.org

I agree that I am filling out this application to the best of my ability for the child listed below, of whom I am the parent or legal guardian.

This field is required

Your Full Name

Today's Date

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

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Client Application Fee

$50

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

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