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Pet Therapy Class Application
(860) 621-9559 Delta Society Pet Therapy Class Application Please print or type clearly Date: ______ HANDLER’S INFORMATION Name: _____________________________ Phone: ___________ Last First Address: _______________________________________________________________ Street Town Zip Code Birthdate: ______________ (*required) E-mail _______________________ Mo/day/year Occupation: ___________________ Employer: ____________________________ Emergency Contact: ____________________________ Phone: ________________ Name Relationship Family Physician: ______________________________ Phone: ________________ Have you been convicted of a felony or imprisoned for any reason? Yes No If yes, please explain on a separate piece of paper. Include all pertinent information. PET INFORMATION Dog’s Name: __________________________________________ Breed: _____________ Age: __________ Has your dog had obedience training? _______________________________________________ Is your dog currently registered by Therapy Dog, Inc.________ or Delta Society________ ***REQUIRED Please attach veterinary paperwork attesting to the health of your dog, including Immunization Schedule and Proof of Rabies Vaccination. ________________________________________________ _______________ Applicant Signature Date Contacts: |
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