Please enable JavaScript in your browser to complete this form. - Step 1 of 7Thank you for your interest in joining Canines for Therapy! Before you are able to become certified, you must submit an application. This application will require you to provide the following: Information on both handler and dog A photo of dog and handler Your dogs most recent vet records Animal Health Screening form completed by your veterinarian Your dogs CGC certification Background check authorization Registration and payment information Please note that you will not be able to submit this application without all of the above. You can find a copy of the Animal Health Screening form by clicking here. NextHandler's InformationName: *FirstMiddleLastAddress: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: *Email: *Date of Birth (mm/dd/yyyy): *What is your t-shirt size? *X-SmallSmallMediumLargeX-LargeXX-LargeXXX-LargeWill you be registering an additional handler? *YesNoAdditional Handler InformationName: *FirstMiddleLastAddress: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: *Email: *Date of Birth (mm/dd/yyyy): *What is their t-shirt size? *X-SmallSmallMediumLargeX-LargeXX-LargeXXX-LargePreviousNextDog's InformationDog's Name: *Breed: *Age: *Microchip Number: *Vest Size: (determined by girth in inches) *XS - 20" or lesSmall - 21"-24"Medium - 25" - 31"Large - 32" -39"XL - 36"-45"Please attach a photo of yourself and your dog. * Click or drag files to this area to upload. You can upload up to 10 files. Please provide your dog's most recent vet records - including the date of their vaccinations. * Click or drag files to this area to upload. You can upload up to 10 files. Please attach the Animal Health Assessment form that has been completed by your veterinarian. * Click or drag files to this area to upload. You can upload up to 10 files. Please attach your dogs CGC certification. Click or drag files to this area to upload. You can upload up to 10 files. Will you be registering an additional dog? *YesNoAdditional Dog InformationDog's Name: *Breed: *Age: *Microchip Number: *Vest Size: (determined by girth in inches) *XS - 20" or lesSmall - 21"-24"Medium - 25" - 31"Large - 32" -39"XL - 36"-45"No additional vest neededPlease attach a photo of yourself and your dog. * Click or drag files to this area to upload. You can upload up to 10 files. Please provide your dog's most recent vet records - including the date of their vaccinations. * Click or drag files to this area to upload. You can upload up to 10 files. Please attach the Animal Health Assessment form that has been completed by your veterinarian. * Click or drag files to this area to upload. You can upload up to 10 files. Please attach your dogs CGC certification. Click or drag files to this area to upload. You can upload up to 10 files. PreviousNextHandler Questionnaire*Answer these questions for each dog that you are registering.*How long have you had your dog? *Has your dog ever been encouraged to be aggressive,trained to bite, or trained in Schutzhund? *YesNoDoes your dog have any history of biting humans as an adult dog? *YesNoPlease explain:List the commands that your dog has been trained on: *Is there a specific population or age group that your dog is uncomfortable around? *YesNoPlease explain: Is there a specific population or age group that your dog is aggressive towards? *YesNoPlease explain: Are there any animals that your dog is reactive towards? *YesNoPlease explain:Does your dog have any known health concerns? *What is your dogs favorite activity? *How does your dog react when they are stressed? *How do you react when you notice that your dog is stressed? *PreviousNextBackground Check InformationA background check will be run using the information that has been supplied on this application. The background check fee is included in the cost of the course.By checking the box below, I authorize Canines for Service, Inc. to obtain background information on me. I understand that any information obtained by Canines for Service, Inc. is confidential and will not be released to any person or outside agency without my written consent and will be used for the sole purpose of assessing volunteer eligibility. *I agreeSocial Security Number: *Additional Handler Background CheckIs the additional handler that you are registering over the age of 18? *YesNoBy checking the box below, I authorize Canines for Service, Inc. to obtain background information on me. I understand that any information obtained by Canines for Service, Inc. is confidential and will not be released to any person or outside agency without my written consent and will be used for the sole purpose of assessing volunteer eligibility. *I agreeSocial Security Number: *PreviousNextAgreements and ReleasesPlease review the agreements and releases below. By checking the box below, I authorize Canines for Service, Inc. to use videos or photographs taken of me during training or therapy activities to be used in promotional materials for the organization. *I agreeI fully understand and agree that (i) Canines for Service, Inc. shall not be liable for any injury or damage to any person(s), animal(s), or to any property, however caused, which results from training or behavior of my pet as well from any negligence on the part of any other pet owner participating in Canines for Therapy and (ii) I will hold Canines for Service and its staff harmless from and against any damages. *I agreeCanines for Service, Inc. shall not be held liable for any costs, attorney's fees or expenses incurred in connection with any claim, action or proceeding occurring as a result of my pet's participation in this program. *I agreeBy checking this box, I acknowledge that my pet is current on all vaccinations required by law. *I agreeAdditional Handler Agreements and ReleasesPlease have your additional handler review the agreements and releases below.By checking the box below, I authorize Canines for Service, Inc. to use videos or photographs taken of me during training or therapy activities to be used in promotional materials for the organization. *I agreeI fully understand and agree that (i) Canines for Service, Inc. shall not be liable for any injury or damage to any person(s), animal(s), or to any property, however caused, which results from training or behavior of my pet as well from any negligence on the part of any other pet owner participating in Canines for Therapy and (ii) I will hold Canines for Service and its staff harmless from and against any damages. *I agreeCanines for Service, Inc. shall not be held liable for any costs, attorney's fees or expenses incurred in connection with any claim, action or proceeding occurring as a result of my pet's participation in this program. *I agreeNextRegistration and PaymentI will be completing my therapy course in: *WilmingtonRaleighCanines for Therapy - Wilmington *New Therapy Team - $ 150.00Additional Handler - $ 50.00Additional Dog - $ 50.00Canines for Therapy - Raleigh *New Therapy Team - $ 85.00Additional Handler - $ 45.00Child Handler (under 18) - $ 25.00Additional Dog (new vest) - $ 65.00Additional Dog (existing vest) - $ 25.00Submit Share this:FacebookX
