| Contact Information |
| Name: |
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| Email: |
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| Street Address: |
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| City: |
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| State: |
ZIP:
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| Home Phone: |
(
)
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| Work Phone: |
(
)
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| How did you learn about Pets for Vets / PAWSitive Therapy Troupe? |
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| Educational Background: |
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| Employment Experience: |
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| Previous Volunteer Experience: |
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| Dog Information |
| Dog's Name: |
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| Breed: |
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| Birth Date: (mm/dd/yy) |
/
/
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| Sex: |
Male
Female |
| Spayed / Neutered? |
Yes
No |
| Did you adopt or purchase your dog? |
Adopt
Purchase |
| From where? |
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| Delta Registration Number: |
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| Expiration Date: |
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| Vet's name: |
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| Street Address: |
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| City: |
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| State: |
ZIP:
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| Describe the training classes that you and your dog have completed: |
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| Titles Earned in Competition? |
Yes
No |
| Has your dog competed for titles in: |
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| Where have you and your dog visited as Delta Pet Partners in the past? |
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| Does your dog have any medical condition(s) that would impact therapy visits? If yes, describe |
If yes, please describe:
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Does your dog have any food allergies?
Yes
No |
If yes, please list:
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Are there any types of people that your dog does not do well with? If yes, describe
Yes
No |
If yes, please describe:
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Is your dog reactive when other dogs are nearby? If yes, describe the behavior and how you deal with it.
Yes
No |
If yes, please describe:
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| Which of the following areas are you and your dog interested in visiting as members of the PAWSItive Therapy Troupe? |
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| Release Statement: I hereby certify that, if accepted as a volunteer into this program, I will keep my dog’s vaccinations, fecal testing, and heartworm prevention treatments current, and will provide proof of such vaccinations, tests results, and treatments on a yearly basis to the program coordinator. I also agree to keep my dog’s Delta Pet Partner registration current and provide proof of such registration whenever my dog is retested. |
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Classes