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-PhoneCell-PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicants AgeMonth of BirthParents Name if applicant is a minorWhat 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 DogHow 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.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
