Name

First Name

Last Name

Street Address

City, State & Zip

Phone

(###)

###

####

Email Address

Pet type

dog, cat, bunny, horse, etc.

Pet's Name

Pet's age

Pet's breed(s)

Describe any experience you have in health care, education, or working with people with disabilities:

List classes or other work or events you have done with your pet:

What is your pet's reaction to other animals?

Why do you think your pet would make a good therapy animal?

What is your general availability?

Where did you learn of Health Heelers?

Are you interested in having your pet screened for therapy potential and readiness?

Have you reviewed and does your pet meet all the Screening Criteria?

Yes

If no, please explain:

Any questions, comments or feedback you'd like to share, please do so here:

APPLICATION