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The form collects medical and diagnostic details, current treatment and medications, daily living impact, restrictions or precautions, and use of adaptive equipment. Additional sections cover employment and vocational rehabilitation contacts, household and pet information, and specific questions about the type of service dog sought and caregiving responsibilities.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-service-dog-parent-and-child-information/278519/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-service-dog-parent-and-child-information/278519.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required about the child and parents/guardians?","Question",{"text":108,"@type":109},"The form asks for parent/guardian contact details and the child’s personal information including name, address, email, phone, age/DOB, and social security number, along with emergency and alternate contacts.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What medical details must be provided?",{"text":113,"@type":109},"Applicants must describe the primary diagnosis and other medical problems, explain how the diagnosis affects daily living skills and limitations, list restrictions or precautions, and provide current medical treatment and medications.",{"name":115,"@type":106,"acceptedAnswer":116},"What caregiving and household details are needed for the service dog?",{"text":117,"@type":109},"The application collects questions about whether the child can physically handle, feed, and participate in grooming the dog, who would assist if not, and asks about the home type, fenced yard plans, who lives in the home, and pets already in the household.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},278519,1790282458,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":15,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":79},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","253 Dayton Ave. Xenia, Ohio 45385 937-374-0385  \nAPPLICATION FOR SERVICE DOG  \nCHILD (Under 18 years of age, or adult who is not their own legal guardian)  \nPLEASE PRINT CLEARLY  \nPARENT INFORMATION-MOTHER  \nName:   Date:   Address:   Email:   City:   State:   Zip:   Phone:   Work:   Cell:    \nPARENT INFORMATION-FATHER  \nName:   Date:   Address:   Email:   City:   State:   Zip:   Phone:   Work:   Cell:    \nCHILDîS INFORMATION  \nName:   Date:   Address:   Email:   City:   State:   Zip:   Phone:   Work:   Cell:   Age / DOB:   Social Security \\# :   \nPLEASE LIST CONTACTS OTHER THAN PARENTíS  \nEmergency Contact: Name:   Phone:   Alternate Contact: Name:   Phone:    \nPhysician:   May we contact? Y / N Address:  Phone:   City:   State:   Zip:    \nInsurance:   If your child has Medicaid, what is the Medicaid number:   If you have Medicaid you need to attach a prescription from your childís doctor.  \nIf Applicable:  \nPhysical Therapist: ____________________________ Phone: _____________________  \nOccupational Therapist: ________________________ Phone: _____________________  \nCase Manager: ________________________________ Phone: ____________________  \nThis form is the property of 4 Paws For Ability, Inc. 1  \nPermission to use all and/or part of this form is prohibited.  \nDiagnosis  \nWhat is the primary diagnosis?   What other medical problems do they have?    \n________________________________________________________________________  \n________________________________________________________________________  \nUse a separate sheet of paper if more space is needed for any question.  \nHow does this affect their daily living skills? What are their limitations?  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nAre there restrictions or precautions as a result of their diagnosis?  \n\n|  |\n| --- |\n|  |\n|  |\n\nWhat type of medical treatment are they currently receiving?  \n\n|  |\n| --- |\n|  |\n|  |\n\nWhat medications are they taking and what are they for?  \n\n|  |\n| --- |\n|  |\n|  |\n\nWhat types of adaptive equipment does your child use (ie. Wheelchair, hearing aid)?  \n\n|  |\n| --- |\n|  |\n|  |\n\nEmployment (For children ages 16 ñ 21 and adult applicants)  \nAre they employed or engage in volunteer activities? Y / N  \nEmployer:   Address:   City:   State:   Zip:    \nPhone:   May we contact? Y / N  \nBasic job duties:    \n________________________________________________________________________  \n________________________________________________________________________  \nDo they have a case with The Bureau of Vocational Rehabilitation? Y`/ N  \nIf so: Counselor name:   Phone:   BVR Address:    \n_______________________________________________________________________  \nThis form is the property of 4 Paws For Ability, Inc. 2  \nPermission to use all and/or part of this form is prohibited.  \nDo they have a Job Coach? Y/N  \nIf so: Name:   Phone:   Agency Name:   Address:    \nDo you have any other social services contacts for your child? Y/N  \nAgency:   Contact:   Address:    \n  Phone:    \nAgency:   Contact:   Address:    \n  Phone:    \nHousehold Information (when families are split please list primary information below and attach a separate sheet of paper with the same information if the dog would be spending any time at the other parentís residence.)  \nType of home: apartment Y / N house: Y / N do you own / rent  \nDo you have fenced yard? Y / N If not, do you plan to fence the Yard? Y/N Who lives in the home?  \nName  Age   Relationship  \n________________________________________________________________________  \n________________________________________________________________________  \n________________________________________________________________________  \nAre there pets in the home?  \nSpecies ( cat, dog, other )and name Age M / F Spayed?  \n________________  \n________________________________________________________________________  \n________________________________________________________________________  \nDo they live inside? Y / N If not: Where do the pets that live outside","cbCaifaAHwd0HIZK","https://ap.wps.com/l/cbCaifaAHwd0HIZK","pdf",123280,"English","# APPLICATION FOR SERVICE DOG\n## Parent Information\n## Child’s Information\n## Medical Information and Treatment\n## Employment and Vocational Support\n## Household and Pet Information\n## Service Dog Information","[{\"question\":\"What information is required about the child and parents/guardians?\",\"answer\":\"The form asks for parent/guardian contact details and the child’s personal information including name, address, email, phone, age/DOB, and social security number, along with emergency and alternate contacts.\"},{\"question\":\"What medical details must be provided?\",\"answer\":\"Applicants must describe the primary diagnosis and other medical problems, explain how the diagnosis affects daily living skills and limitations, list restrictions or precautions, and provide current medical treatment and medications.\"},{\"question\":\"What caregiving and household details are needed for the service dog?\",\"answer\":\"The application collects questions about whether the child can physically handle, feed, and participate in grooming the dog, who would assist if not, and asks about the home type, fenced yard plans, who lives in the home, and pets already in the household.\"}]","APPLICATION FOR SERVICE DOG - Parent and Child Information | PDF",1789510536]