PUPS Volunteer Application Form

PUPS Volunteer Application Form
Please send completed applications to:
VIP Office
c/o Heidi Huebner
205 World Way
Los Angeles, CA 90045
Thank you for your interest in LAX’s PUP Program, a volunteer comfort dog therapy program at LAX.
Please complete all sections of this form. PLEASE PRINT CLEARLY.
SECTION 1: PERSONAL INFORMATION
Name: _______________________________________ Date of Birth (MM/DD): ____________
Address:
City, State, Zip:
Home Phone: ____________________________ Cell Phone: __________________________
E-mail:
Emergency Contact: _______________________________ Phone: ______________________
Employer: _______________________________________ Phone: ______________________
Occupation:
Educational Background:
Languages Spoken:
Please list other ogranizations you have volunteered with your dog and for how long:
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________
4. _____________________________________________________________________
How did you hear about the LAX comfort dog program? _________________________________
______________________________________________________________________________
What are your other interests and hobbies? ___________________________________________
______________________________________________________________________________
SECTION 2: DOG INFORMATION
Name of dog(s):
Breed/Description:
Age of dog(s):
Weight: ____________________ Sex: ________________ Spay/Neutered? Yes
No
Veterinarian Name: __________________________________ Phone: ___________________
Name of Practice:
Date of last vaccines: Rabies ____________ DHLPP ____________ Bordetella ____________
Date of last veterinarian exam:
Please describe any physical or medical restrictions for your dog (e.g. epilepsy, diabetes, heart
problems, arthritis):
____________________________________________________________
____________________________________________________________________________
Is your dog on any medication for these conditions? Yes
Are you the owner of the dog? Yes
No
No
How long? _________________________
Where did you get your dog (breeder, shelter, rescue)?
How old was your dog when you got it?
Did you attend a formal obedience class and graduate together? Yes
No
Please provide the name of your instructor:
Does your dog respond well to basic obedience commands? Yes
Is your dog house broken? Yes
No
No
Has your dog received any awards? _______________________________________________
____________________________________________________________________________
How would your dog respond to a busy airport environment that includes loud noises, elevators,
sudden crowds, unexpected hugs from children, people, being accidently bumped into or
stepped on, wheelchairs, intercom announcements, lots of big luggage on wheels and carts,
etc.?
_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
SECTION 2: DOG INFORMATION CONT.
Please describe the positive and negative traits of your dog:
Positive: _____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Negative: _____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Has your dog ever been asked to leave a facility? Yes
No
Has your dog ever bitten another person or dog? Yes
No
If yes, please explain:
__________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What days and times are you available for a 1-2 hour shift?
____________________________________________________________________________
SECTION 3: CERTIFICATION / REGISTRATION
What certification/registration therapy dog program(s) do you belong to?
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
Please feel free to add or write any other information you would like us to know about:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please provide copies of the following documents. Please note that all documents must
be current.
1.
2.
3.
4.
Certificate of Liability Insurance with Alliance of Therapy Dogs
Copy of Alliance of Therapy Dogs identification card for you and your dog
Any certification for training
Copy of driver’s license
Los Angeles World Airports requires that all badged employees disclose the following
information: Have you ever been convicted of a misdemeanor or felony other than minor traffic
violations?
Yes
(Please initial)
No
(Please initial)
I certify that the statements made in this volunteer application are true and correct and have been
given voluntarily. I understand that I will not be paid for my services as a volunteer. By signing
below, I give VIP Program Management permission to conduct a background check.
Name:
Signature:
Date: