Service/Facility Dog Inquiry

What is a PGI service dog?

Mobility Service Dogs
PGI specializes in training dogs for Mobility Assistance Dogs. These dogs assist people with mobility limiting disabilities. These specially trained dogs help by retrieving objects, pulling wheelchairs, opening and closing doors, turning light switches off and on, barking to indicate that help is needed, and finding another person and leading the person to the handler.

Facility Dogs
A Facility Dog is specially trained to work in tandem with a professional who works with people with disabilities. A dog may provide support in one or more locations with their professional. Public access is permitted only when the dog and handler, is directly working with a client(s) with a disability in a public location.

**WE DO NOT TRAIN DOGS FOR: PTSD-only diagnosis, Emotional support or Personal dogs for service.

Your Details

Todays Date *

Name *

First

Last

Date of Birth *

Email *

Phone *

Your Home Address *

Address Line 1

Address Line 2

City

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Zip Code

How did you hear about PGI? *

Assistance Dog Inquiry

Type of Dog Your applying for *Facility Dog- to work at a school, hospital, etcSkilled Facilitated Service Dog- adult OR child can’t cognitively handle a dog alone so the parent is the certified handlerService Dog- mobility/ wheelchairService Dog- hearingService Dog- medical alertService Dog- other

What is your goal of adding a service dog or facility dog to your life? *

Describe your daily routine? Do you attend school or work? *

Can the applicant handle a dog alone in a public setting like a grocery store? *NoYes

What is your current daily Level of activity Semi Active Active *

• Active (I leave my home daily)
• Semi Active (I leave my home at least 3 times a week)
• Home Bound (I leave my home 1 time a week or less)
• I spend the majority of my day in bed

Describe your Home

Where do you live

• Single Family Home
• Townhome
• Apartment
• Other

Do you rent or own?Home OwnerRent

Please list all current people (and ages) of who live in your home *

Please list all animals (names, type of animals and ages) who live in your home. *

Do you have any foster animals in the home? Do you foster for an animal rescue group? Or do you dog sit?

Are all the animals in the home up to date on vaccinations?NoYes

Are all the animals in the home spayed/neutered?NoYes

Please list your Veterinary Information – Name, Phone number, and address.

Upload proof of vaccinations for animals in your home

Click or drag a file to this area to upload.

Do you have a fenced yard? How do you plan to exercise your dog? *

Have you ever been convicted of a crime? AND/OR animal neglect or abuse? *

• Yes
• No

If yes please describe

Please include photos of the applicant’s home (inside, outside) and yard. *

Click or drag files to this area to upload. You can upload up to 4 files.

SERVICE DOG INQUIRY ONLY

If asking about a SERVICE DOG, what condition/ limitation do you have?

If asking about a SERVICE DOG, How long have you had this condition? Will your condition progress? Please explain.

If asking about a SERVICE DOG, check all that apply

• Use a walker
• Have difficulty with balance
• Use a wheelchair
• Walk at community speed
• Can drive a car
• Make independent decisions for yourself

If asking about a SERVICE DOG, What 3 tasks do you believe a service dog can help you with that would make you more independent (can list more then 3)?

If asking about a SERVICE DOG, Describe how you would feel having a service dog would help you more than having a family pet

If asking about a SERVICE DOG, are you looking for a dog to assist in psychiatric conditions? If yes- please explain.

FACILITY DOG INQUIRY ONLY

If inquiring about a FACILITY DOG, name of facility and address of facility

If inquiring about a FACILITY DOG to assist you in your work, what is your profession? How would you want a dog to assist you in your work?

If inquiring about a FACILITY DOG, who will own the dog. This person will be responsible for taking the dog to work each day and home at the end of day. Please list name and contact information. How long have they been in their current position?

If inquiring about a FACILITY DOG do you have supervisor/ administration approval?

• Yes
• No

If inquiring about a FACILITY DOG to assist you in your work, please list name, address and contact for the administration/ supervisor of the facility.

All Applications- Questions related to our program

Do you currently reside in illinois? *NoYes

Are you able to attend weekly training classes in Peoria IL *

• Yes
• No

Can you afford $600-800 a year for vet care and grooming for a dog? *

• Yes
• No

Are you willing to commit to annual re-certification tests for a working dog and continued training for the life of the dog? *

• Yes
• No

Check to acknowledge agreements before submitting inquiry *

• By signing this I understand Paws Giving Independence reserves the right to deny any applicant for any reason. I understand Paws Giving Independence does not have to give me a reason for a denial of an animal. In my participation with Paws Giving Independence and Helping Paws I do hereby agree to hold free from any and all liability the Paws Giving Independence/Helping Paws and its members, board members, staff, volunteers and officers. My family, members of my household and myself waive the rights and claims for damages and injuries, which may come from connection and participation with PGI. I declare myself to be physically sound to participate with the PGI. I understand PGI can remove a dog from my home at any time due to failure to fulfill these terms, conditions, policies, and procedures of Paws Giving Independence. I understand any dog that is placed with me through Paws Giving Independence will legally belong to Paws Giving Independence until placement paperwork is signed. By providing contact information I am giving PGI permission to contact my vet and references. I understand, service dogs are highly trained in many commands, but they are not machines that will respond automatically to commands. I understand a PGI dog cannot take responsibility for the safety of the recipient.

• I understand PGI will review my information and decided if I am a fit for moving forward with their program. If they would like more information they will email me a complete application to fill out. This Inquiry does not guarantee me acceptance for a service dog. Our recipients are chosen from those who can best benefit from the skills of our dogs.

• The information contained in this online inquiry is correct to the best of my knowledge.

PGI prohibits discrimination based on race, sex (including pregnancy, childbirth or related medical conditions), religious creed, color, national origin or ancestry, physical or mental disability, medical condition, marital status, age, sexual orientation, citizenship status, military service or veteran status, gender identity and gender expression or any other basis protected by federal, state or local law or ordinance or regulation.

Signature *

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It is important for our recipients to learn, gain, and maintain handler qualities. These qualities include quick decision making, good judgment to make the appropriate handling decisions, consistency, and strong memory.

 PGI can only accept a limited number of applications per year due to our volunteers and financial resources. Not everyone who applies for a dog will receive a dog. Recipients must be approved by our board before being taken into the program. If accepted weekly training in Peoria is required.

Minimum requirements to be considered for a PGI dog:

• The individual must have a documented disability.
• PGI must be able to train a dog to help with their specific needs.
• All dogs must be kept in the family’s house.
• All animals in the home must live inside and be kept up-to-date on shots by a vet (the vet will be contacted).
• The potential recipient/family must complete 25 hours of training in Peoria, IL.
• The potential recipient/family must successfully complete three home passes where the dog is exposed to other family animals and family members.
• Recipients must be able to attend weekly classes for one year after receiving the dog.