4 Paws for Ability | Veteran Client Application

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Fields marked with an asterisk (*) are required.

Veteran Client Application

This application is for Veterans of the United States Armed Forces who would be operating as the primary handler of the service dog within three hours of Xenia, OH. Please carefully fill out this application, only fully completed applications with submitted DD214, 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

Personal Information

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

Veteran's First Name

Veteran's Last Name

Street Address

City

State (please use 2 letter abbreviation)

Zip Code

Primary Phone

Secondary Phone

Email (In the future, this will be referred to as your On File Email Address)

Date of Birth

Are you currently on Active Duty?

No Yes

This field is required

Are you a Veteran?

No Yes

This field is required

War of Operation

Describe your time and role in the military

Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Phone

Alternate Emergency Contact's Name

Alternate Emergency Contact's Phone

Spouse/Sponsor Information

Spouse/Sponsor's First Name

Primary Phone

Street Address

City

State (please use 2 letter abbreviation)

Zip Code

Date of Birth

What is the relationship of this person to the client?

Spouse

Relative

Friend

Caregiver

This field is required

If the support person is not a spouse, please explain the relationship

Medical Information

Physician Information

May we contact the Physician?

No Yes

This field is required

Physician's Name

Mailing Address

City

State (please use 2 letter abbreviation)

Zip Code

Phone

If Applicable

Physical Therapist's Name

Phone

Occupational Therapist's Name

Phone

Description

What is your primary diagnosis?

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

What other medical conditions do you have?

Is your disability combat related?

No Yes

This field is required

What is your disability rating?

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

Do you have any restrictions or precautions as a result of your diagnosis?

What type of medical treatment are you currently receiving?

What medications are you currently taking and what are they for? (Please list name and use for each)

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

Do you have a psychiatric diagnosis?

No Yes

This field is required

If yes, please describe the psychiatric diagnosis

If yes, are you on medication to assist with the psychiatric diagnosis?

No Yes

This field is required

Insurance

Employment Information

Are you employed or a volunteer?

No Yes

This field is required

Employer

Address

City

State (please use 2 letter abbreviation)

Phone

Basic Job Duties

May we contact your employer?

No Yes

This field is required

Spouse/Sponsor's Employer's Information

Spouse/Sponsor's Employer

Address

City

State (please use 2 letter abbreviation)

Zip Code

Phone

May we contact Spouse/Sponsor's employer?

No Yes

This field is required

Household Information

Type of Home

Other House Apartment

This field is required

If type of home is other, please explain

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, please list your 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 from now until at least one year after the service dog is placed to give the service dog time to adjust and bond appropriately.

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 not, where do the outdoor pets reside?

For these current pets, 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?

N/A No Yes

This field is required

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

Veterinarian's Practice Name

Veterinarian's Phone

How long have you used this veterinarian?

Maintaining a Service Dog

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. 4 Paws for Ability is not currently a member of Assistance Dogs International. The VA uses membership as the determining factor of whether they will financially provide for the dog's care. 4 Paws for Ability Veteran Applicants should be prepared for a cost of around $1,500-$2,000 each year in caring for their service dog.

Are you financially prepared to care for a service dog?

Other No Yes

This field is required

Can you physically bathe and groom the dog?

No Yes

This field is required

If not, are you financially prepared to pay grooming?

No Yes

This field is required

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

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

Service Dog Information

To be the handler of the service dog, the individual must be capable of making 100% correct choices for themselves and the service dog.

Are you physically able to independently handle the dog?

No Yes

This field is required

What help would be needed in handling the service dog?

If you are not able to, who will handle the dog for you?

Who will handle the service dog in public?

Who will handle the service dog in the home?

Please explain the handler situation and list all who would potentially handle the dog

What are the thoughts of the members of your family about the service dog? What do they believe the benefits of the service dog will be?

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 want 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

www.4pawsforability.org

Are you willing to sign a contract?

No Yes

This field is required

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

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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