Contact Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Driver's License Number

Date of Birth

YYYY

Dog Information

Name

Breed

Gender

Male

Female

Birth Date

Dog's Date of birth

YYYY

Availability

Checkbox

What are the best times to contact you?

Weekday Mornings

Weekday Afternoons

Weekday Evenings

Weekend Mornings

Weekend Afternoons

Weekend Evenings

Best way to contact you

Home Phone

Work Phone

Cell Phone

Volunteer Visit Requests/Interests

Tell us in which areas you are interested in volunteering

Assisted-living Facilities

Community Events

Day Care Centers

Hospice Centers

Hospitals

Nursing Homes

Schools

Working with Special Needs Children

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.

Previous Volunteer Experience

Summarize your previous volunteer experience.

Emergency Contact Information

Person to Notify in Case of Emergency

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Agreement and Submittal

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a member with U.S.A. Therapy Dogs, Inc. any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. **It is U.S.A. Therapy Dogs, Inc. policy to screen our potential members for criminal sexual and violent felony charges. By submitting this application, you are agreeing to allow U.S.A. Therapy Dogs, Inc. to perform a background check. The reason for this is some of the facilities (e.g.: day cares, hospice centers, schools) will require a Federal background check.**

Our Policy

It is the policy of U.S.A. Therapy Dogs, Inc. to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in becoming a member with us. COST: $250 FOR 1 DOG AND 1 PERSON COST: $300 FOR 1 DOG AND 2 PEOPLE

Membership Application

USA Therapy Dogs, Inc.