Home / Application Requests Application Requests *Please click here before completing the application to ensure that we serve your specific area. Client Application Thank you for your interest in receiving a PAWS Assistance Dog. In an effort to better meet the needs of our future and current clients PAWS has an annual application request time period for all first-time applicants. Application request forms will be available for a non-refundable $25 fee from January 4 – March 31, 2020. During this time you will be able to request an application to receive a Service Dog to help with physical disabilities, a Hearing Dog to alert to common environmental sounds, a Seizure Response Dog to aid you during or after your seizures and Service Dogs for Children with Autism. Please check our website for the qualifications to receive each type of Assistance Dog and for additional program requirements. At this time PAWS does not train Psychiatric Service Dogs to assist with PTSD, anxiety, or depression or Diabetic Alert Dogs, or Guide Dogs for the visually impaired, or for individuals with Traumatic Brain Injuries (TBI). For the 2021 open enrollment we are not able to take application requests for any individual with impaired balance unless they use adaptive devices such as a wheelchair or scooter when outside their home. If you have, or have had a PAWS Assistance dog and are in need of a Successor Dog, please contact PAWS directly by calling 616-877-7297 or e-mailing us at csdirect@pawswithacause.org. Please be aware that in order for PAWS to place an Assistance Dog with you, we must have a local Field Representative in your area and that coverage is subject to change at any time. PAWS has Field Rep coverage East of the Mississippi River and Arizona. Please click on the link at the top of the page to ensure that we serve your specific area. Click here for more information on the types of Assistance Dogs we provide. All fields are required. Applicant First Name Applicant Last Name Name of person completing this form Relation to Applicant Applicant Cell Phone Number Home Phone Number Are you a Veteran Yes No If someone in your immediate family is a veteran please check all that apply. Spouse/Significant Other Child Parent How did you hear about Paws With A Cause? Applicant Address Applicant Address Applicant Address Applicant Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Email Please understand that due to the increased demand for Assistance Dogs nationwide, the demand far outweighs the supply. Not everyone that applies will be able to receive a PAWS Assistance Dog. The $25 application fee is nonrefundable. What would you like an Assistance Dog to do for you? I acknowledge that I have read the Applicant FAQs and Application Process. Click here to review our FAQS if you have not already done so Yes I acknowledge that my disability has been diagnosed by a medical professional at least one year prior to submitting my application to PAWS. Yes No I acknowledge that everyone 18 years of age and older living in my household will undergo a background screening Yes No List any cognitive disabilities (i.e. Down Syndrome, short/long term memory loss, dementia, dyslexia, Attention Deficit Disorder and other learning disabilities) or enter none. Please answer the following questions regarding your ability to provide and care for an Assistance Dog, which may weigh as much as 90lbs. Are you able to afford a minimum of $1200 a year for the upkeep and care of your PAWS Dog? Yes No If no, please provide the name and phone number of the person who has agreed to assist you financially with the upkeep and care of the dog Are you able to provide daily exercise for your Assistance Dog? Yes No Please Explain Are you able to take your Assistance Dog out multiple times throughout the day for bathroom breaks? Yes No Please Explain Are you able to have your Assistance Dog bathed and groomed every three months? Yes No Please Explain Are you able to practice and physically train with your Assistance Dog on a daily basis? Yes No Please Explain A PAWS Assistance Dog will not be placed in a home with any other dog, unless it is a retired PAWS Dog or working Assistance Dog from an Assistance Dogs International or International Guide Dog Federation-accredited agency for someone else in the household. It has been our experience that other dogs in the home can interfere with the bonding and training process of the Assistance Dog Team. If you currently own a dog, do you agree to re-home it prior to receiving your Assistance Dog? Yes No Dog Paws With A Cause is frequently asked if we have any non-shedding or hypoallergenic dogs. Before we answer the question, it helps to know what the inquiries mean by the term and why they are asking. Some people are looking for no or low-shedding dog because they do not want dog hair on their clothes/rugs/furniture, etc. Others have allergies - or family members with allergies - and are looking for what is commonly know as a "hypoallergenic dog." Contrary to popular belief, a dog's hair is not the primary problem for most people with dog allergies. Dog dander and saliva, which sticks to the dog's hair and are shed into the home or transferred to human skin or clothing when the dog is touched, are the chief allergens for most people. To help those with dog allergies, baths will reduce the allergen problem for all types of dogs. Generally, a larger dog will produce more dander than a smaller one; and a dog that barks frequently may disperse more saliva and dander into the air than a quiet dog. But there are also breed differences in the amount of allergens produced and in the amount of hair the dog will shed. Is the applicant allergic to dogs? Yes No What level of reaction do they have? (Signs/Symptoms) Is anyone in the household allergic to dogs? Yes No What level of reaction do they have? (Signs/Symptoms) How will you address the allergies if a dog is placed in the home? Do you need a hypoallergenic dog? Yes No Please explain why. What type of Assistance Dog are you applying for? Hearing Dog (for a person who is deaf or hard of hearing) Service Dog (for people with physical disabilities) Seizure Response Dog Service Dog for A Child with Autism (child must be between 4 - 12 years of age (PAWS must receive the application prior to a child’s 7th birthday; must have a completed Needs Assessment by a child’s 9th birthday; placement must occur prior to a child’s 12th birthday) Combination Dog: Service and Hearing Combination Dog: Service and Seizure Combination Dog: Hearing and Seizure I acknowledge that I was born before March 31, 2003 * Yes Hearing Loss: Please list all diagnosed disabilities and date of diagnosis Hearing Loss: What tasks or skills would you like a Hearing Dog to do for you? Hearing Loss: Which type of hearing loss have you been diagnosed with? Bilateral Unilateral Hearing Loss: Please provide the month and year the diagnosis was made Hearing Loss: Which sounds do you need a Hearing Dog to alert you to? Hearing Loss: Do you have a preference for dog size? Small Large No Preference I acknowledge I was born before March 31, 2007 * Yes Physical Disabilities: What is the primary disability for which you are applying for a Service Dog? Physical Disabilities: Please provide the month and year the diagnosis was made Physical Disabilities: List all other disabilities Physical Disabilities: When was each diagnosed? Physical Disabilities: What tasks or skills would you like a Service Dog to do for you? I acknowledge that PAWS is not placing dogs with any individual with impaired balance, unless they use adaptive devises such as a wheelchair or scooter when outside their home * yes Seizures: Have you been diagnosed with epileptic seizures? Yes No Seizures: Please provide the month and year the diagnosis was made Seizures: I understand that a PAWS Seizure Response Dog does NOT predict seizures. Yes No Seizures: I understand that a PAWS Seizure Response Dog will NOT provide protection. Yes No Seizures: I understand that a PAWS Seizure Response Dog will NOT guide me to safety Yes No Seizures: I understand that a PAWS Seizure Response Dog will NOT roll me over. Yes No Seizures: Please tell us how often your seizures occur Seizures: What types of seizures do you have? (grand mal, petit mal, partial-complex, cluster, absence, etc.) Seizures: What is the frequency of each type of your seizure (daily, weekly, monthly, etc.)? Seizures: What tasks or skills would you like a Seizure Dog to do for you? Assistance: What tasks or skills would you like an Assistance Dog to do for you? Autism: Has your child been diagnosed with Autism? Yes No Autism: Please provide the month and year the diagnosis was made I acknowledge that my child was born AFTER March 31, 2014 * Yes Autism: My child exhibits (check all that apply) Meltdowns at home Meltdowns at school Meltdowns in public Kicking, hitting, pinching, or biting Wandering Fixating on specific objects Bolting Not sleeping well Self-stimulation Anxiety or fears of places or objects Autism: My child also exhibits... Autism: My child is currently in (check all that apply) An ongoing education program Physical Therapy Speech Therapy Occupational Therapy Recreational Therapy OtherOther Autism: Do both parents live in the same home? If not, will both parents be facilitators for the placement? Autism: Please list all of the addresses where the child will reside. Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Add Remove Autism: Please describe the effects of autism on the child and the family. Application Fee There is a $25 fee to request a new client application. I acknowledge that I have read the areas that PAWS serves and that my $25 application fee is non refundable * Yes Billing First Name Billing Last Name Billing Address Billing Address Billing Address Billing Address City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Credit Card Credit Card Credit Card Credit Card Month 1 2 3 4 5 6 7 8 9 10 11 12 Credit Card Year 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 CVV (3-digit security code from back of card) CVV (3-digit security code from back of card) Submit If you are human, leave this field blank.
