VIP Dog Teams Program Application The person who will visit with the dog must complete this form. If you are not the owner, you must provide written proof of permission to handle this dog. Certification with VIP Dog Teams Therapy Programs only applies during VIP sponsored activities. The liability insurance will not cover you during any other therapy related programs or activities. Please indicate YES or NO that you understand these restrictions. (see below) Preliminary Information I have read the information at the top of this form and understand that liability insurance related to VIP Dogs certified therapy dog teams only covers sponsored activities of this organization. YesNo I am interested in the VIP Programs, working with health care, educational professionals YesNo If yes, please select the programs that interest you. Virtual Dog TherapyAdult visitPup Club (Children's Reading Support Program) I am available to volunteer during the following times/days. Please describe your availability. Owner's Info First & Last Name (required) Handler's Info First & Last Name (required) Address (required) City (required) Zip Code (required) Home Telephone (required) Mobile Telephone (required) Your Email (required) Emergency Contact's Name (required) Emergency contact phone (required) Handler's Education/Employment Please tell us a little about your educational background. Include any relevant training, vocational schools, workshops, etc. Indicate Emphasis and/or Major. Enter information about your employment history. Are you currently still working? How many hours? Please give us the names of two personal or business contacts who can act as references on your behalf (no family members). Include person's name, daytime number and relationship. Reference #1 Name Phone Relationship Reference #2 Name Phone Relationship What organizations do you currently volunteer for or have volunteered for in the past? Where/how did you acquire your dog companion? How long have you had or known this dog? What training has your dog had? Do you train with Operant Conditioning methods? (i.e. positive reinforcement & clicker training) YesNo Are there any environments that your dog avoids or that may cause stress? YesNo Please explain: Are you and your dog certified with any therapy dog organizations? YesNo If yes, please give details and name of organization(s) Dog Information Dog’s Name Dog's Age Date of Birth Breed/Description Gender MaleFemale Spayed/Neutered Spayed/NeuteredNot Dog’s City/County License YesNo License Number Behavioral Information Has your dog ever bitten another dog? YesNo If yes, please explain. Does your dog sleep inside at night? YesNo Is your dog housebroken? YesNo Does your dog signal to go outside? YesNo Does your dog toilet on command? YesNo Does your dog behave while being bathed? YesNo Is your dog allowed on the furniture at home? YesNo Why do you think your dog would be good for this program? Are you an alumni team of the VIP Dogs Training Prep School? YesNo If so, what date was the class? If not, describe you and your dog's experiences in therapy volunteering. With what age group do you believe you and your dog would be most effective? How do you praise/reward your dog? Does your dog have any consistent annoying behaviors you would like to change? (Please describe) List any outstanding behaviors that your dog does well (e.g. tricks, accomplishments, different habits) How does your dog react around other dogs? (Please elaborate on any incidents which include any of the following: growling, snapping, snarling, excessive barking at, lunging towards, or biting.) Were incidents on or off leash? OnOffNot applicable Has your dog ever acted in a threatening or menacing manner towards an individual or group of individuals? (Threatening/menacing includes overt staring, growling, snapping, snarling, barking at, lunging toward or biting an individual.) YesNo If so. describe below. How did you respond? Is your dog currently working as a therapy dog? YesNo If yes, please give details and name of program if certified. Are there any specific age groups that your dog avoids or seems uncomfortable around? (i.e. Infants, Adult Women, Adolescents, Adult Men, School Age children, Toddlers, Seniors, Other?) YesNo List all that apply and briefly describe. Are there any specific animals that your dog does not react well with? YesNo Please describe/identify. What are your dog's favorite games or activities? How do you discipline or correct your dog? What does your dog do when he/she becomes stressed? What do you do when you recognize signs of stress in your dog? Describe why you are interested in volunteering and what you hope to get out of it. Thank You for your interest in our program! By submitting this form, you agree that to the best of your knowledge and belief, all the statements made above are true/complete/accurate.