Paws 4 Liberty -- Changing Lives...One Dog At a Time


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SERVICE DOG APPLICATION

* Required


*First Name:
*Last Name:
*Birth Date:	mm/dd/yyyy
*Email:
*Address Line 1:
Address Line 2:
*City:
*State:
*ZIP/Postal:
*Phone:
Alternate Phone:
Facebook?	Yes No
*How did you hear about us?	Forgotten Soldiers Independence Fund Petsmart Facebook Internet Search Personal Referral Other
*Type of dog applying for:	Service/Skilled Companion Emotional/Psychiatric Support
*What is your disability?
*How long have you been disabled?
Who else lives at home with you?
*How does your disability limit your current level of independence and/or ability to function?
*Do you spend part of your day away from your home?	Yes No If Yes, please describe the situation. Include information about how the presence of a service dog would be received by those in charge.
Have you already rescued or adopted a dog you would like to have trained or train yourself?	Yes No
Do you have a training partner to help you complete the last stage of service dog training?	Yes No If Yes, state name and relationship:
Are you applying for a Facility Dog (a dog that will serve many people in a group facility) ?	Yes No If Yes, describe your facility and the tasks our service dog will provide for your residents. Who is filling out this application for the facility and what is your role?
*Is anyone in your household allergic to dogs, afraid of them, or reluctant to participant in the training process?	Yes No If Yes, please explain why:
I acknowledge that I have read the FAQ and agree to the policies and procedures of Paws 4 Liberty and its trainers and their representatives. *Agree

Paws 4 Liberty, Inc. * 8939 Palomino Drive * Lake Worth, FL 33467