Please complete this application form if you are interested in becoming a OSF HealthCare Animal Assisted Therapy Volunteer. Once you complete the form, click the Continue button at the bottom.

Name and Address

First name:

Last name:

Middle:

Nickname:

Street:

City:

State:

* Zip: *

I'm at this address year-round?:

Home phone:

Cell phone:

Email address:

Birth Date:

Employment:

Full Time

Out of Workforce

Part Time

Retired

Employment

Employer Name:

Occupation:

Are you currently Dog/Therapy Certified?

Check the box, if you are currently Dog/Therapy certified?

Dog/Therapy Certified:

If you checked the box, which organization?

Dog Information

Provide necessary information or check the boxes that apply.

Dog's Name:

Breed:

Dog Birthday:

Weight:

Veterinarian:

Male:

Female:

Neutered:

Dog lives with me:

Is your dog currently on year round Flea & Heart Worm Protection? What brand?

Has your dog attended any obedience classes?

Check the box, if your dog attended any obedience classes?

Attended Dog Obedience Classes:

Where and what level was completed?

Volunteer Availablility

Volunteers will be required to work at least twice per month. Please indicate your preferred shifts.
Sunday/Monday: 9:30-11:30am or 6-8pm
Tuesday: 6-8pm
Wednesday/Thursday/Friday: 1:30-3:30pm
Saturday: 9:30-11:30am

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

How often would you like to Volunteer?

Where do you hear about this program?

Please write a short paragraph on why you would like to participate in this program.

Health Requirements

This volunteer position requires a moderate to high amount of walking and standing. If you have a small dog, it will also require a moderate to high amount of lifting your dog onto the patient's bed.

Do you or your dog have any physical limitations?

Conviction Records

Have you ever pled guilty to or been convicted of a crime other than a minor traffic offense? This does not include minor traffic violations or convictions that have been sealed or expunged.

Conviction Record:

Yes

If yes, please explain:

When finished with this application...

Select "Continue" at the bottom of this form **or** print it out and send your completed application to:
Kathy Perry
Director Patient Experience
OSF Saint Anthony Medical Center
5666 East State Street
Rockford, IL 61108
Phone: 815-227-2515 | Fax: 815-227-2592

CAREFULLY READ THIS:

TRAINING COMMITMENT

Selected qualified applicants will be invited to have their dog's temperament tested. You will be notified of the next scheduled temperament testing. Handlers and dogs chosen for this program must attend a mandatory 2 day intensive training. As a result, your sevices aill be contracted exclusively to OSF HealthCare. Following the successful completion of your training, handlers will submit paperwork to register their dogs as a therapy dog.

You understand the time and financial commitment involved with becoming an OSF HealthCare certified dog/handler. You understand that your services will be exclusive to OSF HealthCare. You also understand that your dog must receive annual vaccinations and be on year round heart guard and flea protection. You fully accept all the terms and conditions stated above by checking the "I Agree" box and selecting the "Continue" button below.

AGREEMENT WITH THE TERMS AND POLICIES

I hereby affirm that the information on this application is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for a volunteer position and may result in discharge even if discovered a later date.

I understand that as part of the application process, that a criminal background check may be conducted. I understand that OSF HealthCare is not obligated to provide placement, nor are you obligated to accept a position if one is offered. Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, or sex.

I Agree