Todays Date:
Your name:
Your email address:
Cell number:
Your phone number:
Street Address
City
State
Zip
Applicants Age
Parents name is 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
You are applying for what type of assistance dog?
Mobility Assistance Dog
Facility Dog
Veteran's Dog
Autism Assistance Dog
Diabetic Alert  Dog
CLICK HERE to go to description of dogs page
Pawsitive Action Foundation Inc. & The Canine Center,Inc
5701 Leon Tyson Rd Saint Cloud Fl 34771        407-461-6245 or 407-506-3818 (txt only)
Assistance Dog Training Application
Click HERE to return to the home page