Your Basic Information

Last Name:   First Name: 

Street Address   City:

State:  Zipcode Day Phone:

Evening Phone:   Fax:

E-mail address

More About You

How often can you commit to visiting a facility? Weekly Every other week Monthly

Days and times available:

Are you comfortable being around disabled people? Yes   No

Do hospitals bother You?   Yes   No    Do Hospital Smells Bother You?   Yes   No

Are you comfortable around walkers and wheelchairs?    Yes   No 

Previous activities with your pets:


Related volunteer activities or professional experience:


Do you have formal training in related subjects including medical, education, psychology, social services, veterinary medicine or others?



Why do you want to participate?


About Your Pet

Is your pet older than one year of age?    Yes   No   Is your pet friendly with other animals?   Yes   No

Is your pet comfortable with men, women and children?   Yes   No  

Has your pet ever bitten anyone?   Yes   No

Is your pet obedience trained?   Yes   No    Does your dog have a "Canine Good Citizen" title?   Yes   No

Is there anything else you would like to tell us about yourself or your pet?


Please be sure that you have filled out the form completely and then press the submit button.