General Information
Date:
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First Name
*
Last Name
*
Email Address
*
All volunteers are required to work minimally once every other week. We currently have the following shifts (Check all that apply):
Saturday and Sunday (2:30 pm-4:30 pm)
Monday, Wednesday, Friday (2:30 pm-4:30 pm)
Tuesday, Thursday (6:00 pm-8:00 pm)
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Home Phone
*
Work Phone
*
Cell Phone
*
Street Address 1
Street Address 2
*
City
*
State
AK
NV 1
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Zip
*
Occupation
*
Employer
*
How did you hear about the program?
*
Have you ever done dog therapy work with your dog named on this application?
Yes
No
Where?
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Are you currently Therapy Dog Certified?
Yes
No
If yes, by which organization?
Date of Certification
Dog Information
*
Dog Breed
*
Age
*
Dog Birth Date
*
Dog's Name
*
Gender
Female
Male
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Weight
*
Has your dog attended group obedience classes?
Yes
No
Trainer used, how long ago, and what level was completed?
*
Is your dog currently on year around Flea Protection?
Yes
No
Flea protection brand?
*
Heart worm brand
*
Veterinarian
*
Phone
*
Does your dog live with you?
Yes
No
How long?
*
Please write a paragraph about why you are interested in participating in this type of program.
Volunteer Shifts
*
How many days/week would you like to volunteer?
*
How many days/month would you like to volunteer?
*
Are you a year around resident at the address listed above?
Yes
No