OSF Saint Anthony Medical Center
Rockford, Illinois

Paws 4 Healing

ANIMAL ASSISTED THERAPY VOLUNTEER APPLICATION

* indicates a required field.

General Information
* First Name:
* Last Name:
* Address:
Address:
* City:
* State:
* Zip Code:
* Are you a year around resident at the address listed above?:	Yes No
Home Phone:
Cell Phone:
* Birth date:
* E-mail:
Occupation:
Employer:
* Are you currently Dog/Therapy Certified?:	Yes No
If yes, which organization?:
Dog Information
* Dog Name:
Breed:
Dog Birth Date:
Weight:
Gender:	Male Female
Neutered:	Yes No
Has your dog attended any obedience classes?:	Yes No
If yes, where?:
If yes, what level was completed?:
Is your dog currently on year around Flea Protection?:	Yes No
What brand?:
Heart Worm brand?:
Veterinarian:
Veterinarian Phone:
Does your dog live with you?:	Yes No
How long?:
Volunteer Availability Volunteers will be required to work at least twice per month. Please (x) your preferred shifts.
9:30a.m. – 11:30a.m.:	Every other Sunday Every other Monday Saturday
1:30p.m. – 3:30p.m.:	Wednesday Thursday Friday
6p.m. – 8p.m. :	Every other Sunday Every other Monday Tuesday
How often would you like to volunteer?:
“How many days/month would you like to volunteer?:	2 times a month required
How did you hear about the AAT program?:	Please write a short paragraph on why you would like to participate in this program.
Why would you like to participate in the AAT program?:
Health Requirements This volunteer position requires a moderate to high amount of walking and standing. If you have a small dog it will also require a moderate to high amount of lifting your dog onto the patient’s bed.
* Do you or your dog have any physical limitations? :	Yes No
If yes, please explain:
Conviction Records
* Have you ever pled guilty to or been convicted of a crime other than a minor traffic offense? This does not include minor traffic violations or convictions that have been sealed or expunged.:	Yes No
If yes, please explain:
TRAINING COMMITMENT Select qualified applicants will be invited to have their dog’s temperament tested. You will be notified of the next scheduled temperament testing. The cost for this testing is $20.00 made payable to the OSF Saint Anthony Foundation. Handlers and dogs chosen for this program must attend a mandatory 2 day intensive training. As a result, your services will be contracted exclusively to OSF Saint Anthony Medical Center. Following the successful completion of your training, handlers will submit paperwork to register their dog as a therapy dog.
* I understand the time and financial commitment involved with becoming an OSF Saint Anthony certified dog/handler. I understand that my services will be exclusive to OSF Saint Antony Medical Center. I also understand that my dog must receive annual vaccinations and be on year round heart guard and flea protection. I fully accept all the terms and conditions stated above:	I Understand
CAREFULLY READ THIS SECTION PRIOR TO SUBMITTING THIS FORM I hereby affirm that the information on this application is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for a volunteer position and may result in discharge even if discovered at a later date. I understand that as part of the application process, that a criminal background check may be conducted. I understand that OSF Saint Anthony Medical Center is not obligated to provide placement, nor are you obligated to accept a position if one is offered. Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, or sex.

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OSF Saint Anthony Medical Center Rockford, Illinois

Paws 4 Healing

ANIMAL ASSISTED THERAPY VOLUNTEER APPLICATION

General Information

Dog Information

Volunteer Availability

Health Requirements

Conviction Records

TRAINING COMMITMENT

CAREFULLY READ THIS SECTION PRIOR TO SUBMITTING THIS FORM

OSF Saint Anthony Medical Center
Rockford, Illinois