Pet Therapy - Canine Owner Application

I am over the age of 18. I am NOT a High School student
Personal
Family/last name
First name
Street Address
City
State
Zip/postal
Home phone
Mobile
E-mail
Emergency Contact
Name
Home phone
Mobile
Current / Most Recent Employer
Business Phone
Supervisor Name
Pet Therapy Information
Have you been certified as a team?
When were you certified?
Name of certification facility or evaluator
Where would you be most interested in serving?
Do you have previous experience as a pet therapy team? If so, where?
What date are you available to begin volunteering? (A minimum 6-month commitment is required)
Please check your preferred shift(s)
Yes
No
Have you had a Tuberculosis test within the past 12 months?
Influenza vaccination (flu shot) is required for all volunteers. Flu shots will be available free of charge at Hartford Hospital beginning in late October. I understand that I must have documentation of a current flu shot to volunteer during flu season.
** Please remember to complete the Canine Application for your pet.