Service Dogs Florida Application | Genesis Assistance Dogs, Inc.

In order to apply for an assistance / service dog, please fill out and submit the following form.

"*" indicates required fields

Name*

First Last

Email*

Home-Phone

Cell-Phone

Address

Street Address Address Line 2 City State ZIP Code

Applicant's Age

Month of Birth

Parents 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.

Name

This field is for validation purposes and should be left unchanged.

Service Dog Application