In order to apply for an assistance / service dog, please fill out and submit the following form. "*" indicates required fields I understand that I am applying for a Mobility Assistance Dog.* By checking here I understand that I am applying for a Mobility Assistance Dog.DO NOT COMPLETE THIS APPLICATION IF YOU ARE LOOKING FOR: Autism Dogs, ANY Medical Alert Dogs, PTSD, Emotional Support Dogs, Therapy Dogs or Facility Dogs. WE ONLY CONSIDER APPLICATIONS FOR MOBILITY ASSISTANCE DOGS!Name* First Last Email* Home-PhoneCell-PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant's AgeUnder 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerMonth of BirthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberParents Name if applicant is a minor What do you think an Assistance Dog can do for you?Primary Disability: Cause of Disability: Effects of Disability: Mobility Aids: How did you hear about Genesis Assistance Dogs?PLEASE NOTE: As of March 2021, our waiting time from initial application approval to placement of an assistance dog is approximately 1 - 4 years.NameThis field is for validation purposes and should be left unchanged. Δ
