Apply On-Line

P.A.D. APPLICATION

Please complete the form below to begin your enrollment process.

Please note that the following documents must be submitted to PAWS/LA before we can complete your enrollment:

• Proof of Los Angeles County residency (California Driver’s License, utility bill, or rental agreement
• Proof of Income (SSI and/or SSD award letter; bank statement)
• Proof of Medical Disability & Diagnosis (Physician’s letter confirming disability due to illness)
• Proof of spay/neuter of your companion animal. (Veterinary certificate)
• Companion Animal Information Form
• Client Services Agreement

1. First Name: (required)
2. Last Name: (required)
3. Gender:
4. Male
   Female
5. Birthdate: (ex: 11/16/1982) (required)
6. Social Security#: (required)
7. Street Address: (required)
8. City: (required)
9. Zip Code: (required)
10. Primary Phone Number: (required)
11. Secondary Phone Number:
    (Include only if we can leave messages for you at this number.)
12. Email Address: (valid email required)
13. Area in Los Angeles County in which you live:
14. Antelope Valley (1)
    San Fernando Valley (2)
    San Gabriel Valley/E, Los Angeles (3)
    Hollywood/Downtown (4)
    Santa Monica/W. Los Angeles (5)
    South Los Angeles (6)
    East L.A. County (7)
    Long Beach/South Bay (8)
15. Is it OK to leave a message from PAWS/LA?
16. Yes
    No
17. Can you receive mail at this address?
18. Yes
    No
19. Cross streets?
20. Do you have transportation?
21. Yes
    No
22. How did you hear about PAWS/LA?
23. Diagnosis:
24. AIDS
    Symptomatic HIV
    Asymptomatic HIV
    Other
25. Do you have a social worker or case manager?
26. Yes
    No
27. If yes, Name:
28. Agency:
29. Phone:
30. Race/Ethnicity:
31. Hispanic/Latino
    Native American/Alaskan Native
    Asian
    Black/African American
    Native Hawaiian/Other Pacific Islander
    White
    Native American/Alaskan Native and White
    Asian and White
    Black/African American and White
    Native American/Alaskan Native and Black
    Other Multi-Racial
32. Current housing situation:
33. Emergency Shelter or No Housing
    Temporary Housing
    Private Housing
    Jail/Prison/Juvenile Facility
34. Bedroom Composition:
35. Single
    1 Bedroom
    2 Bedrooms
    3 Bedrooms
    4 Bedrooms
    5 Bedrooms
    Other
36. Number of people in household:
37. Gross Monthly Income:
38. No income
    $1-$150
    $151-$250
    $251-$500
    $501-$1,000
    $1,001-$1,500
    $1,501-$2,000
    $2,000+
39. Emergency Contact Name: (primary) (required)
40. Relationship:
41. Phone Number: (required)
42. Emergency Contact Name: (secondary)
43. Relationship:
44. Phone Number:
45. Please provide information on who will adopt your companion animal(s) should the need arise. Also, please keep all health records and registration information for your companion animal(s) in order and readily accessible.
46. Name:
47. Address:
48. City:
49. State:
50. Zip code:
51. Phone:
52. 
    CONSENT TO RELEASE INFORMATION/STATEMENT OF FACT. By typing your full name and the date below, you agree to the following:
    I hereby authorize PAWS/LA and its representatives to share/access information with/from relevant agencies regarding services I have received and/or requested. And, I hereby certify that the information I have provided to PAWS/LA is true and correct to the best of my knowledge. I also understand that any false information provided to PAWS/LA may result in termination of services.
    (required)