Patriot PAWS Service Dog Application

Date (mm/dd/yyyy)

Service Dog

Any Veteran is welcome to apply and will be considered on a case-by-case basis.
We will be performing a background check on all applicants applying for a Service Dog.

General Information

Patriot PAWS will only review completed applications. A complete application is one that includes ALL requested documentation.
Sending in an application does NOT mean you are automatically approved. Once submitted, your application will go before our Veteran Committee for tentative approval.
Once tentatively approved, please understand that placement may take 1-3+ years. It is required that you contact the Veteran Coordinators MONTHLY during this time.
If approved, you must be financially able to travel to Texas, and provide your own accommodations for twelve days.
Patriot PAWS considers ALL applications regardless of age, race, sexual orientation, or religion.

In order to ensure that each Service Dog Team is successful, it is the policy of Patriot PAWS that if a Service Dog is to be placed in a home where more than one pet is present, we reserve the right to deny placement.

Because of this policy, we encourage you to also apply with other agencies.

Please Initial: I have read and understand the above information.

Facility Visit

You will be required to visit our Patriot PAWS facility in Rockwall, Texas. If a facility visit is not feasible, you must contact the Veteran Coordinators to discuss other possible arrangements.

Documentation

Upon submission of this application, you will receive a link to additional required documents. In order to complete your application process, you will be required to submit the following:

A copy of your DD214, or equivalent for Reserve Component Veterans
A VA compensation letter (Annual Award Letter/Disability rating will be sufficient) *found on e-benefits*
Two Family Care Plan letters
An employer letter
Medical History completed by your medical or mental health provider. Medical History will not be accepted by any other source other than your medical provider.
A HIPAA Authorization for Release
An acknowledgement of Patriot PAWS rights to approve/deny applications and act in the best interest of any Patriot PAWS dog

Documents can be mailed to:

Patriot PAWS Service Dogs
c/o Veteran Coordinators
254 Ranch Trail
Rockwall, TX 75032

Faxed to:

754-799-3812

Or scanned and emailed to:

veterans@patriotpaws.org

Pre-Qualifying Questions

Are you willing to attend a twelve-day training course at one of the Patriot PAWS training facilities in Texas, at your own expense?

Are you willing to wait 3+ years in order to receive a Service Dog?

Are you financially able to cover the expense of a Service Dog, i.e., Vet Visits, Food, etc.?

Are you willing to undergo a background check?

Personal Information

First Name

Middle Name

Last Name

Referred By

DOB (mm/dd/yyyy)

Gender

Weight

Height

Marital Status

Spouse (if applicable)

Street Address

City

State

Zip

Phone (Home)

Email Address

Phone (Cell)

Text Message?

Preferred Method of Communication

VA Disability Rating

Employed?

Emergency Contact

Name

Relationship

Street Address

City

State

Zip

Phone (Home)

Phone (Cell)

Military Background

Branch of Service

Component

Years of Service

Start/End (mm/yy - mm/yy)

Pay Grade

Type of Discharge

Strength Assessment

Please rate your physical strength on a scale of 1 to 10.
1 = WEAKEST and 10 = STRONGEST

Right Hand

Left Hand

Right Arm

Left Arm

Upper Body

Back

Right Leg

Left Leg

Symptom Checklist

1 = Mild, 2 = Moderate, 3 = Severe, N/A = Not Present

Anger/Irritability

Anxiety

Delusions

Depression

Dissociation

Hallucinations

Impulsivity

Mania

Obsessions

Paranoia

Social Isolation

Other Symptoms

If you selected "3" for any of the above, please explain:

History of Addiction (substances/alcohol)

Home Environment

Please list any others living in the same household (name, age, gender, relationship):

Please list any household pets (species, breed, age, gender, spayed/neutered):

Fenced Backyard?

If no, please explain plan for exercise:

Who is the primary caretaker of the household pets?

Are current pets up to date on vaccines and preventions (heartworm/flea/tick) according to your state laws?

Does anyone residing with you have any concerns about having an assistance dog in your home?

If yes, please explain:

Media Release

Patriot PAWS Service Dogs periodically uses forms of media (i.e., photography, video, audio, footage, testimonials) for publicity, social media (Facebook, Twitter, Instagram, YouTube, Tik Tok, LinkedIn) and/or educational purposes. By signing, I acknowledge that I have received this document and give permission to Patriot PAWS Service Dogs to use my likeness (including first name, pictures, and video) in the above forms of media.

E-Signature

Date (mm/dd/yyyy)

I understand that I have the right to revoke this authorization at any time, and it must be submitted in writing to the Compliance Officer at:

Terri Stringer/HIPAA Compliance Officer

Patriot PAWS Service Dogs

254 Ranch Trail

Rockwall, TX 75032

Frequently Asked Questions

If my application is denied for a Service Dog, is there a way that I can file a dispute?
Of course. If you would like to dispute the decision, we ask that you write a letter to our Veteran Committee.

Who is my point of contact at Patriot PAWS Service Dogs?
The Veteran Coordinators will be your point of contact.

Am I placed on a waiting list?
Our Veterans are placed into a pool rather than a list. We understand that each Veteran has unique needs and that some needs may need more immediate attention. However, this is contingent on the dogs we have available for each graduation. This is why we prefer to have a pool of Veterans to select from instead of a list.

What is the cost during the 12-day graduation period?
You should plan for over $110/night(this includes taxes) for your hotel, and ~$45/day for your meals. Your plane ticket, gas, rental cars etc., will all be contingent upon the month you are here for graduation as these costs fluctuate frequently