This application is for your DOG.

First Name on the application is the dogs name.

Last name on the application is the owner's last name.

Date of birth is the dogs date of birth.

Please complete this application for your DOG, to become a Penrose-St. Francis Volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

First name:

Last name:

Address:

City:

State:

* Zip: *

Date of birth:

Gender:

Location:

Centura Health Primary Care

Penrose Hospital - 2222 N. Nevada Ave.

PSF Physican Practice Primary Care

St. Francis Medical Center - 6001 E. Woodmen Rd.

Registration

Current registration through Alliance of Therapy Dogs or Pet Partners. Registration from other organizations will not be accepted.

Certified through:

Requirements

We only accept dogs that have already been certified. All required documentation must be provided to our office along with a completed application prior to being invited to a volunteer orientation.

Dog must be at least 1 year of age.

Must send current vaccines and membership ID to:

Mairin Hurtado

Volunteer Services

Penrose-St. Francis Health Services

2222 N. Nevada Ave.

Colorado Springs, CO 80907

mairinhurtado@centura.org

Must be docile and of friendly temperament. Note: If the behavior of the pet is/or becomes unmanageable i.e. barking, the visit will be terminated.

Breed of Dog

Emergency Contact

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Condition and Commitments of Volunteering

*The Volunteer Services Department reserves the right to decline any application.

Our Mission: We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities.

Our Vision: Centura Health will fulfill a covenant of caring for our communities with excellence and integrity to become their partner for life.

Centura Health's seven core values:

?Compassion

?Respect

?Integrity

?Spirituality

?Stewardship

?Imagination

?Excellence