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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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