Pet Therapy Volunteer Application

Moffitt Cancer Center's Pet Therapy Program is committed to making a positive impact in the lives of patients by offering animal-assisted interactions, activities and therapy in a consistent manner, to ensure the safety of all participants.

All volunteers are required to be registered and remain in good standing with one of the following three pet therapy certifying organizations:

Pet Partners
Alliance of Therapy Dogs
Project PUP

Moffitt Pet Therapy Program

Moffitt Cancer Center does not permit the following breeds: Pitbull, Rottweiler, Bull Mastiff, German Shepherd, Wolf-Hybrid or any mixed breed of the above. Applicant dogs must also be spayed or neutered in order to participate in Moffitt's Pet Therapy Program.

Therapy Dog Information

Please list responses below:

Name

Breed

Pet Therapy Certification Organization

Date of Certification

Applicant Contact Information

First name:

Last name:

Middle name:

Nickname:

Street 1:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Social security number:

Type of Visa:

Would you like to opt-in to text messaging?

Yes Not now

What kinds of email would you like to receive?

Volunteer Services Information
Volunteer Services Updates and Communications

Volgistics Volunteer Alerts sends reminders, alerts, and custom messages from System Operators and Coordinators. Use this section to opt-in and opt-out of text messaging (also known as "SMS"), and initially set how you would like to receive messages. Your messages can be delivered as emails, text messages, or none. You can change this at any time through VicNet. View supported phone carriers.

Mobile phone:

Country:

Receive automated
messages between:

and

Time zone:

Choose how you would like to receive the following types of messages:

Custom Messages

with Text

Notification

None

Volunteer Services Information
Volunteer Services Updates and Communications

I agree to the Terms and Conditions.

Message and Data Rates May Apply. For help or information on this program send "HELP" to 28344. You can send "STOP" to 28344 at any time to opt out. For additional assistance, call 888-891-6978 or click here. Message frequency based on account settings. Messages are not guaranteed to be delivered. All messages will be sent by email until you respond "YES" to the welcome text message sent after the application form is submitted. Message preferences can be changed in VicNet on the Account tab.

Demographic Information

Date of birth:

Gender:

Education:

Race:

Ethnicity:

Uniform Size (S,M,L,XL,XX,XXX:

Background Check

Have you ever been convicted in a court of law, pleaded no lo contendere, been placed on probation or had adjudication withheld to an offense other than a minor traffic violation. Please answer yes or no. If yes, please explain:

Background Check

Are you legally eligible to volunteer in the United States? Please answer yes or no.

Emergency Contact

First name:

Last name:

Home phone:

Cell phone:

Relationship:

How did you hear about Moffitt's volunteer program

Choose one or more:

If Other, please explain:

Why would you like to volunteer with Moffitt?

Day(s) and Time(s) Available for Placement

Site Preference

Magnolia Campus:

McKinley Outpatient Campus:

Moffitt International Campus:

Moffitt Wesley Chapel:

Are you a current or former Moffitt Team Member?

Moffitt Team Member:

Current Moffitt Team Member

Former Moffitt Team Member

Not a Team Member

I Agree

By checking "I agree" and submitting the Moffitt Cancer Center Volunteer Application, you affirm that you are compliant with Moffitt's Covid Vaccination requirement.

I Agree