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.

Comments
This field is for validation purposes and should be left unchanged.
Applicant Name & Email
Name*
First Last
Email*
Contact Information
Home-Phone
Cell-Phone
Address
Street Address Address Line 2 City State ZIP Code
Applicants 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:
By checking here I understand that I am applying for a Mobility Assistance Dog.
- Mobility Assistance Dog
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.

Service Dog Application – Part 2