Paw Partners Pet Therapy Application Form
Fields marked with an asterisk are mandatory.
Contact Information
* First name:
* Last name:
Nickname:
* Street address:
* City:
* State:
* Zip code:
Home phone: (e.g. 215-590-0000)
Work phone: (e.g. 215-590-0000)
Cell phone: (e.g. 215-590-0000)
* Email address:
* Confirm email address:
* Date of birth:
Languages spoken:
Employer / School Information
Education & Experience:
middle school
high school
college - 1 year
college - 2 years
college - 3 years
college degree
graduate degree
Employer:
Position:
College:
High school:
Availability
Availability:
Sun
Mon
Tues
Wed
Thu
Fri
Sat
Morning
Afternoon
Evening
Emergency Contact Information
* First name:
* Last name:
* Home phone:
Work phone:
Cell phone:
Relationship:
General Information
Are you a current CHOP employee?
yes
no
Have you ever been employed at CHOP?
yes
no
If yes, reason for leaving:
Is any family member a CHOP employee?
yes
no
If yes, name of family member:
Please list any past or current volunteer experience (organization, duties, & service dates)
How did you learn about our Volunteer Program?
CHOP website
CHOP employee/volunteer
School/College
Other
If other, please specify:
* Why are you interested in volunteering at CHOP?
Please describe your experience working with children, including your own:
Please share with us any additional information about special skills you may have:
Dog Information (Name and History)
* Dog name:
Dog date of birth: (if known)
* Breed:
Coat length:
* Weight:
* Gender:
Is your dog a wolf hybrid?
Yes
No
Are you willing to have your dog medically and behaviorally screened through The Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania at no charge to you?
Yes
No
Certification Information
All Paw Partner therapy dogs must be certified by a CHOP approved agency. Please indicate which agency has certified your therapy dog.
Delta Society
Comfort Caring Canines
Therapy Dogs Incorporated
Therapy Dogs International
* Address:
* Phone number:
* Certification number:
Veterinarian Information
* Name:
Street address:
City:
Zip code:
Phone number:
Any major medical history or illnesses?
Yes
No
If yes, explain:
Is the dog currently on any medications?
Yes
No
If yes, explain:
Dog's Behavior
* How does your dog relate to men?
* How does your dog relate to women?
* How does your dog relate to children?
Does your dog dislike any of the following?
other dogs
being excessively touched
tiled or slippery floors
strange objects
loud noises
other
Volunteer Agreement
I certify that the information provided on this application is true and complete to the best of my knowledge, and agree that falsified information or significant omissions may disqualify me from further consideration from volunteering and, if I am accepted to be a volunteer, will result in my dismissal when discovered. I understand that, if accepted as a volunteer, I will be required to abide by all the policies, rules and regulations of the Hospital. I authorize the Hospital to investigate all statements contained in this application and to make inquiries of my personal references and medical history, as well as other related matters as may be necessary for arriving at a decision of acceptance into the volunteer program. I hereby release employers, schools or individuals from all liability in responding to inquiries relative to my volunteer application.
I Agree
