Patriot PAWS Facility Dog Application

Date

Facility Dog

At Patriot PAWS Service Dogs, we have learned that dogs can be beneficial to a particular group, facility, or organization. Facility Dogs are dogs with limited public access, servicing the facilities that these organizations work out of. If you are thinking of applying one of our lovable dogs as a Facility Dog, please consider the following:

Patriot PAWS Service Dogs acquires dogs from a variety of sources. These include, but are not limited to: breeders, rescues, donations, and shelters. Consequently, some of our dogs are purebred while others are mixed breeds.
The dogs that are offered for Facility Dog placement may have some type of medical, behavioral, or temperamental problem inhibiting them from receiving full public access. These issues will be disclosed to you before the placement takes place.
We review all applications received. Dogs are paired with recipients based on the information provided in your application and on an evaluation our trainers will perform. This information will allow us to find the best match.
Patriot PAWS reserves the right to deny an applicant based on information provided to us about a potential recipient.

If you are interested in receiving one of our dogs as a Facility Dog, please fill out the application. After we receive your application, you will be placed on our current list of applicants. You will receive an e-mail or phone call once a suitable match is determined. You are welcome to e-mail or call to check on the status of available dogs.

General Information

All applicants are required to have a secondary handler who is also willing to attend any required training for Facility Dog placement.
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 a committee for tentative approval.
You must be willing to facilitate an in-home and facility visit with a Patriot PAWS representative. This may be in person or virtual.
You must provide up to date vaccination history on any current dogs and cats at your residence.
If approved, you must be available for three to four days of training, as well as annual recertifications with a Patriot PAWS representative.
Patriot PAWS considers ALL applications regardless of age, race, sexual orientation, or religion.

In order to ensure that each Facility Dog Team is successful, it is the policy of Patriot PAWS that if a Facility 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.

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 letter from your employer
A Family Care Plan letter
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 Jackie Fox
254 Ranch Trail
Rockwall, TX 75032

Faxed to:

972-772-3284

Or scanned and emailed to:

jackie@patriotpaws.org

Organization Information

Organization Name

Street Address

City

State

Zip Code

Facility Phone Number

Facility Fax Number

Point of Contact (This person will be the main caretaker of the Facility Dog)

Point of Contact - Title

Secondary Contact (This person will be the secondary caretaker of the Service Dog)

Secondary Contact Title

Please tell us how your organization would benefit from a Patriot PAWS dog:

Do you or the caretaker(s) have any experience with dogs? If yes, please explain:

Please tell us any information you would like us to know when considering placing a Patriot PAWS dog with your organization:

Describe the organization/facility the dog would be around daily:

Where/how did you hear about Patriot PAWS Service Dogs?

Facility Environment

How many employees are within your facility?

How many people, not including employees, would the Facility Dog interact with?

Who would benefit from the Facility Dog?

Where will the Facility Dog be kept during the day?

Where will the Facility Dog be kept at night?

Does anyone within your facility/organization have any concerns with having a Facility Dog on premises? If so, please explain:

Describe the specific needs of your facility that the Facility Dog would be assisting with:

Primary Caretaker - Personal Information

Name (First Last)

Date of Birth

Street Address

City

State

Zip Code

Phone Number

Text (Y or N)

Do you have any experience with dogs? If yes, please explain:

Primary Caretaker - Home Environment

Where do you currently reside?

Other:

If renting your home, do you have written permission from your landlord to own a dog? You will be asked to provide proof of written permission before adoption is completed.

Please list anyone currently residing in your household: (Name, Gender, Age)

Other than the children residing in your home, will the dog be exposed to children on a regular basis? If yes, please explain:

Please list any pets currently residing in your household: (Type, Breed, Age)

Do you have a fenced in yard?

Does anyone in your household have any concerns of having an assistance dog in your/his/her home? Do they not want to have a dog in the house? If so, please explain:

Please tell us any other information you would like us to know when considering placing a Patriot PAWS dog in your home:

Please Be Advised

It is the policy of Patriot PAWS Service Dogs that if a Facility Dog is to be placed in a facility/home where more than one pet is present, we reserve the right to deny placement. We must make sure that the Facility Dog team is successful.

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

Veterinarian

Do you have a veterinarian? If yes, please provide the clinic name:

Veterinarian Address:

Veterinarian Phone Number:

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

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

Please feel free to attach any additional documents to support your application for a Patriot PAWS Facility Dog