Pet Therapy

*Highlighted fields are required

Owner Information

* First Name

Middle Initial

Last Name

Date of Birth (mm/dd/yyyy)

Home Address

Apt.#/Suite

City

State

Zip

Phone (Home)

Phone (Mobile)

E-mail (This e-mail address will be used for all ongoing correspondence).

Emergency Contact

* Name

* Relationship

* City/State/Postal

Phone (Home)

Phone (Mobile)

Connecticut Children's Employee Referral Information

Do you have relatives employed at Connecticut Children's? If YES, please complete name, relationship, and department information below.

Name of Person who Referred you:

Relationship

Department

Availability

Availability - Pet Therapy shifts are typically every other week and last between 1 - 2 hour visits. Additionally, shifts are typically Monday - Friday 10 A.M. - 6 P.M. Schedule will be created based on unit need and handler availability. Please select typical availability.

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Prior Service History

Have you or any family member ever received service at Connecticut Children's or any of their satellite locations?

If YES, date of most recent visit

Employment Information

Are you presently employed?

If yes, what kind of work do you do?

Pet Information

* Name

* Breed

* Weight

* Sex

* Date of Birth

* Certification Organization

* Certification #

* Certification Date

* Certification Expires

Veterinarian Information

* Name

* Address

* Phone

* Date of last physical exam

Part I - Immunization Dates

Rabies

* Received

* Expires

DHLPP

* Received

* Expires

Bordetella

* Received

* Expires

Fecal Exam

* Date

* Results

Questionaire

Does your dog exhibit any of the following behaviors? (please check all that apply)

Urinates in House

Defectates in House

Jumps on People

Barks Excessively

Chews

Digs

Bites People

Becomes Carsick

Been in a Dog Fight

Chases Cats/Birds

Jumps on Furniture

Other

Other (Please specify):

Does your dog dislike:

Other Dogs

Strange Objects

Elevators/Stairs

Cats

Slippery Floors

Loud Noises

Other

Other (Please specify):

Is your dog 100% housebroken?

Does your dog follow a raw meat diet?

How does your dog indicate a need to go out?

Do you have previous experience as a pet therapy team? If so, where?

Does your dog have any tricks or have special talents? If yes, please explain:

Has your dog been obedience trained? If yes, please provide when and where:

Does your dog understand hand signals or verbal cues? If yes, please explain

Is there anything your dog has been trained not to do? Please explain:

Please comment on how your dog relates to people:

Additional Information

All required documentation listed below must be submitted for your aaplication to be considered complete.

Please tell us a little bit about why you would like to volunteer as a Pet Therapy Handler at Connecticut Children's.

Any additional comments you would like to make regarding your dog or the Pet Therapy Program?

I currently have an insurance rider through my certifying organization of at least 1 million US dollars.

If accepted into the program, would you be willing to submit to a criminal background check?

I understand that any volunteer joining Connecticut Children's during flu season will be required to show documentation of a current influenza vaccination, and an annual vaccination is mandatory for continued participation in the program.

* Current photo of you

* Photo of your dog

By submitting my application, I understand that Connecticut Children's will consider me for a volunteer position on the basis of the information I have furnished on this application form, and that any false, misleading or incomplete statements made by me, or any omission of material fact shall prevent my volunteering or shall be cause for immediate dismissal from my volunteer assignment.

I understand that the staff of the Volunteer Services Department will be conducting a background check on me prior to being placed. As part of the volunteer application process, and at any time during my volunteer placement, I authorize Connecticut Children's or any of its affiliates to obtain the record of any conviction for commission of a felony.

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