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Caring Canines Therapy Dog Club of Southern Vermont - Application for Membership
Regular Member ($35.00) � Household Membership ($50.00) � Supporting Member ($20.00)
Payment of dues will be collected upon successful completion of dog/handler evaluation.
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* Required
Email
*
Your email
Owner Information
Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Telephone
*
Your answer
Dog Information
Name
*
Your answer
Breed
*
Your answer
Sex
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Color
*
Your answer
Number of Dogs in Household
*
Choose
1
2
3
4
5
More than 5
Spayed/Neutered
*
Yes
No
In order to help us better understand you and your dog, please complete as much of the information below as you are comfortable with. If not applicable, please indicate with ‘NA’
How did you become aware of Caring Canines?
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Your answer
List other clubs to which you currently belong:
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Your answer
On what club committees have you served and/or what club related activities have you been involved with?
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Your answer
List any dog related areas of interest:
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Your answer
If accepted as a member of the C.C.T.D.C. of S.VT., what would you most look forward to?
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Your answer
What is your perception of a therapy team?
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Your answer
What type of visits you are interested in doing?
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Nursing home
Adult Day Care
Children’s Reading Program
Animal Assisted Therapy
Other
Required
Can you commit to at least 5 visits a year?
*
Yes
No
Unsure
Why do you believe that your dog is suited to therapy work?
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Your answer
List any activities in which your dog has participated
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Your answer
Does your dog have a Canine Good Citizen certificate (CGC)?
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Yes
No
Describe the level of your dog’s obedience experience
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Your answer
Is your dog shy or nervous around crowds of people (describe)?
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Your answer
Does your dog get along well with children (describe)?
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Your answer
How does your dog act with multiple dogs and people in the room?
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Your answer
How does your dog handle stress (describe)?
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Your answer
What do you do as a handler to address this?
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Your answer
What types of collars and leashes do you use?
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Your answer
Has your dog ever bitten a human being?
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Yes
No
Unsure
Is your dog hand shy?
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Yes
No
Unsure
Has your dog ever been involved in a dog fight?
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Yes
No
Unsure
Describe you dog (check all that apply)
*
Adaptable
Outgoing
Timid
Shy
Hyper
Friendly
Calm
Reliable
Required
Are you interested in participating in workshops offered by Caring Canines?
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Yes
No
Maybe
Do you belong to another Therapy Dog organization? If yes, which one?
*
Your answer
Do you swear that the information submitted here is true and correct to the best of your knowledge and understanding?
*
Yes
A copy of your responses will be emailed to the address you provided.
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