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Home
About
Our Dogs
Success Stories
How to Apply
Ways to Help
Gallery
Blog
Contact

Home
About
Our Dogs
Success Stories
How to Apply
Ways to Help
Gallery
Blog
Contact

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Home
About
Our Dogs
Success Stories
How to Apply
Ways to Help
Gallery
Blog
Contact

Service Dog Application

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

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-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 January 2019 our waiting time from initial application approval to placement of an assistance dog is approximately 24 – 30 months.
Name
This field is for validation purposes and should be left unchanged.

Genesis Assistance Dogs, Inc.

Mailing Address:
P.O. Box 3101, West Palm Beach, FL 33402
info@genesisassistancedogsinc.org
(561) 329-0277

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