Before completing this application, please read the Capital Therapy Dogs Playbook, available on our website on the More Info page. It's an easy read - just a few pages!

The Capital Therapy Dogs Application for Provisional Membership is Phase 2 of our membership process. Please complete this application form after you have met with one of our volunteer Greeters as described in our Playbook. Please fill out the Contact Us Form on our website to set up a meeting. Once you have met with our Greeters and are ready to apply to become a Capital Therapy Dogs volunteer, fill out this form and click the Continue button at the bottom.

Questions? email capitaltherapydogs@gmail.com. Thanks!

Handler Details

First name:

Last name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Do you have any special needs or accommodations?

Dog Details

Dog 1 Name:

Dog 1 Breed:

Enter any additional information about your dog that you'd like us to know.

REQUIRED: Rabies Certificate Information

California law requires that all dogs must be current on the Rabies vaccine.

Enter your dog's Rabies vaccine expiration date:

REQUIRED: Fecal Test

Capital Therapy Dogs requires an annual, negative fecal test result.

Enter the date of your dog's latest negative fecal result:

Dog Health

Handlers must carry proof of current Rabies vaccine and negative parasite test. In addition, overall good health of the dog is important.

Describe your dog's health:

Spay/Neuter

If you wish to join Capital Therapy Dogs with an intact dog, your application requires additional evaluation by the Board of Directors.

Is your dog spayed or neutered?

Dog Temperament

Describe your dog’s temperament:

Dog Interaction

How does your dog get along with other dogs?

Availability and Interests

When do you anticipate being available to volunteer? What types of programs are you interested in attending?

Emergency Contact

Please provide someone we can contact in an emergency.

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Email address:

Veterinarian

Please provide contact information for your veterinarian.

Reference

Please provide at least one personal or professional reference.

1

2

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Email address:

Provisional Applicant Agreement

By signing this agreement, I attest that I have read and agree to the CTD Playbook, and will:

• Attend six CTD programs with my dogs as a provisional member for a period of six months, at which time the CTD Board will provide me with a determination regarding registration as a CTD member.

• Represent CTD in a professional and friendly manner.

• Treat clients, CTD members, Board and Officers with respect.

• Protect client privacy and confidentiality.

• Be clean and in good health when my dog and I attend CTD programs.

• Clean up after my pet.

• Use safe and clean equipment to handle my pet, including a four foot or shorter leash.

• Be responsible for my pet at all times and ensure that my pet stays on leash and under my control at all times.

• Remain alert to the interactions between my pet and clients.

• Watch my pet for any signs of stress and remove my pet from a program if necessary.

• Refer any questions or concerns to a CTD Program Liaison or Board member.

Assumption of Risk and Waiver of Liability

1. Inherent Risk: The undersigned is engaged as a volunteer in therapy dog programs and recognizes that there are inherent risks in acting as a Capital Therapy Dogs (CTD) handler/dog team. Such risks include but are not limited to, animal bite, injury from property or equipment, or exposure to infectious diseases. The undersigned understands that personal and property damage, personal injury and death may result from, among other causes, the active or passive negligence of CTD, its Board, Officers and members, and may result from participation of any kind in CTD activities and situations, including transportation of the undersigned and their animal to and from activities.

2. Release of Liability: The undersigned releases CTD, its Board, Officers and members from liability connected with acting as a handler/dog team to the undersigned and the undersigned’s representatives, guardians, successors, assigns, heirs, and next of kin for any and all liability, claims, damages or demands injury, or death, including but not limited to third parties, or injuries to the undersigned and the undersigned’s dog, including but not limited to the those arising from the inherent risks described in the preceding paragraph. This release includes, without limitation, any personal or property damage, personal injury, or death caused by the active or passive negligence of CTD, its Board, Officers or members with respect to any action, claim or action against the undersigned by a third party. The undersigned bears sole responsibility and liability for any loss. The undersigned also assumes complete risk for any family member or guest that has accompanied them to any activity.

3. Knowing and Voluntary Execution: The undersigned acknowledges that he or she (1) has carefully read this agreement and (2) has understood its contents, including the release of CTD, its Board, Officers and members from liability for negligence. The undersigned further acknowledges that CTD, its Board, Officers and members are materially relying on this waiver in allowing the undersigned to participate as a representative of CTD in any and all CTD activities and situations.

4. Animal Temperament: I state that my animal is not aggressive towards people or other animals.

I Agree