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Pets On Wheels of Scottsdale, Inc.

A Visiting Therapy Dog Organization

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Pets On Wheels of Scottsdale, Inc.

VOLUNTEER APPLICATION

Step 1 of 3

33%

Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
E-Mail Address
Marital Status:
- Single
- Married
- Divorced
- Widowed
Full Name of Spouse/Significant Other:
Name of Emergency Contact:
Relationship
Home Phone
Work Phone
Do you live in Arizona
- Full-Time
- Part Time
Retired
- Yes
- No
Current or Former Work Occupation
Name of Company
Type of business

Tee Shirt
Tee Shirt Size
- Small
- Medium
- Large
- Extra Large
What has been your experience with fragile elders, the memory-impaired or disabled children?
List 1 reference who is not related to you:
Reference Name
First Middle Last
Reference Address
Street Address Address Line 2 City State ZIP Code
Reference Home Phone
Reference Cell Phone
Reference Work Phone
Relationship to you
How long have you known?
Other types of help you may be able to provide to the program
- Media relations (news articles, displays
- Photography
- Fund Raising
- Training & Orientation
- Dog Training
- Computer Skills

Section Break
Pet Information:
Pet’s Name*
Sex*
Age*
Breed*
Color*
Weight*
Spayed or Neutered?*
- Yes
- No
Date of Last Rabies Shot:*
Name of Clinic*
Clinic Phone*
Name of Veterinarian:*
Veterinarian Phone*
Pet License Number*
Issued By*
Date Issued*
Date Format: MM slash DD slash YYYY
Where did you first meet your pet?*
- Shelter
- Breeder
- Other
Obedience:
Basic Training
- Yes
- No
Where?
AKC Registration
- Yes
- No
SR#
Canine Good Citizen (CGC) by the American Kennel Club:
- Yes
- No
AKC Therapy Dog Certification (THD)
- Yes
- No
Highest Title
AKC obedience trials?
- Yes
- No
Highest Title
Is your dog certified by other therapy groups?
- Alliance of Therapy Dogs
- Pet Partners
- Therapy Dogs
- International
- Other Group
If Other Group
Tell us about your pet and any tricks:
Do you have other pets in your home?
- Yes
- No
If yes, what kind of pets?
How many other pets?
Please enter a number from 0 to 50.
PETS ON WHEELS LIABILITY

I hereby release Pets on Wheels of Scottsdale from any and all liability or responsibility due to injury or loss that either I or my pet(s) may incur as a result of any participation in any Pets on Wheels sanctioned visit to a visitation site or other function in promotion of Pets on Wheels. Pets on Wheels volunteers are covered with liability insurance should they or their pet damage or injure others while they are representing Pets on Wheels of Scottsdale, Inc. Many dog owners also have a provision in their home owner’s insurance policy to cover damage or injury caused by their pet(s).
Signature*
Date*
Date Format: MM slash DD slash YYYY

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