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Service Dog Application

Thank you for your interest in the Heroic Paws Inc. Service Dog Program. Please complete this application in
its entirety. Submission of an application does not guarantee acceptance into the program.
Applicant Name Date of Birth Parent/Guardian Name (if applicant is under 18) Address City State Zip Phone Number E-mail
Preferred Method of Contact
Phone
Email
Text Message
Please select all that apply
Veteran
First Responder
Child with Disability
Autism Support
Psychiatric Service Dog
Mobility Assistance Dog
Medical Alert Dog
Other
Number of Adults in Home Number of Children in Home Ages of Children Do you own or rent your home? Do you have a fenced yard? Please list all pets currently living in the home. Have your pets lived with other dogs? Please describe the disability or condition for which you are seeking a service dog. How would a service dog improve your quality of life?
What tasks would you like the service dog to perform?
Anxiety Alert
Deep Pressure Therapy
Nightmare Interruption
Medical Alert
Medication Retrieval
Mobility Assistance
Item Retrieval
Autism Support
Other
HEALTHCARE PROVIDER INFORMATION - Provider Name Practice Name Phone Number Email May Heroic Paws contact your provider? PROGRAM PARTICIPATION - Heroic Paws places puppies between 8 and 12 weeks of age and requires active participation in training. Are you willing to participate in: Weekly Training Sessions? Virtual Coaching Sessions Home Practice Assignments Public Access Training FINANCIAL INFORMATION Funding assistance may be available based on need. Would you like to be considered for financial assistance? Can you contribute financially toward your service dog's care and training? REFERENCES - Personal Reference #1 Name: Relationship Phone E-mail Personal Reference #2 Name Relationship Phone E-mail AGREEMENT I understand that: • Submission of this application does not guarantee acceptance into the Heroic Paws Inc. program. • Heroic Paws Inc. reserves the right to approve or deny any application. • I am responsible for providing accurate information. • I agree to participate in training and follow program guidelines if accepted. • I understand that service dog training requires significant time, commitment, and participation. Applicant Signature Date Parent/Guardian Signature (if applicable) Date HEROIC PAWS INC. OFFICE USE ONLY Date Received Application Review Date Interview Completed Home Assessment Completed
Application Status
Approved
Waitlist
Denied
Reviewer Notes Submit