Pet Therapy Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell phone

Alternate Phone #

Email

Type of Animal

Dog
Cat

List

Pet's Name	Breed	Age

Is your pet up-to-date on their shots?

Please have your vet email us your pet's shot records to [email protected]

Yes
No

Does your dog bark, get nervous or anxious around other people, animals, noises or new environments?

Yes
No

If Yes, please explain

Does your pet have any health problems or limitations we should know about?

Yes
No

If Yes, please explain

Has your pet been exposed to different sights, sounds, people and other animals on a regular basis?

Yes
No

How often do you anticipate participating in our program? Once a month, every other month, a certain month?

How did you hear about the program?

Please Read

All applicants are subject to screening. While we would love for all pets to be eligible, some do not fit the criteria we have set for this program. Our main concern is the health and well being of all involved.

It you are interested in having your dog registered with Therapy Dogs International, please contact the office for more information. This registry can provide you with liability insurance and offer you and your dog added credibility in the Pet Therapy industry.

Children are also welcome to come along with parents and pets.

For questions, comments, or concerns please contact us at 847 816-0831 or email to [email protected]

I HEREBY UNDERSTAND AND AGREE WITH THE ABOVE APPLICATION

Bringing people and pets together through education, therapy, and rescue

Pet Therapy Volunteer Application

Please Read