Pre-Screen Form for Volunteers

PRE-SCREEN FORM Your Name: Dog's Name: Address: City: County: Please choose the County in which you live Bergen Berkshire Bronx Columbia Dutchess Fairfield Greene Hudson Kings (Brooklyn) Litchfield Nassau New Haven New York (Manhattan) Putnam Queens Richmond (Staten Island) Rockland Suffolk Ulster Westchester Other State: Please choose the State in which you live Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Home phone: Work phone: Cell phone: Email: How did you hear about The Good Dog Foundation and its training program? Dog's Breed: Dog's Gender: Male Female Dog's Date of Birth: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Is your dog Neutered or Spayed? Yes No How long have you had your dog? Select a timeframe Less than one year 1 years 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years Where did you get your dog (rescue, adoption, breeder, etc.): Have you taken any classes or worked with a trainer with your dog? Yes No If so was it in a group or private setting? Group Private Can your dog do any of the following on command? Sit Yes No Down Yes No Stay Yes No Does your dog do any tricks? Please explain Does your dog pull you when you walk him/her on a leash? Yes No Do you use a choke chain or prong collar? Yes No If so, will your dog respond to commands with a flat collar? Yes No Does your dog have exposure to other dogs? Yes No If so, is the exposure on or off a leash? On Off How does your dog react to other dogs? Please explain. Has your dog been exposed to children? Yes No If so, what ages? If so, how does he/she react? Has your dog been exposed to elderly people with wheelchairs, walkers, etc.? Yes No If so, how does he/she react? How does your dog react when meeting a stranger or new person? Please explain his/her usual mannerisms. If your dog is a small dog, can he/she be held by a stranger? Yes No If not, please explain why. Is your dog in good health? Yes No Is he/she on any medication? Yes No If so, please list. Has your dog been vaccinated for rabies in the last year? Yes No Name of vet and clinic for your dog Does your dog have any sensitive areas where he/she may not like to be touched? (i.e., feet or tail) Yes No If so, please list. Does your dog have any places he/she particularly likes to be touched? Yes No If so, please list Is your dog afraid of anything like thunderstorms or fireworks? Yes No If so, how does he/she react? Has your dog ever done any of the following: Growled? Yes No Bitten any person or animal? Yes No Drawn Blood? Yes No If you answered yes to any of the above, please explain the circumstances. What are your dog's best qualities? What does your dog love to do the most? Have you and your dog ever visited a hospital? Yes No If so, how did your dog react? What are your goals for you and your dog in The Good Dog Foundation's animal assisted therapy program? Please share some of your own interests and background Have you had any experience volunteering for other causes? Yes No If so, what type of volunteer work? When are you available to visit as a therapy team? (days, times, etc.) When are you available for a pre-screening with a trainer? Do you have any preference of patient population or facility? Yes No If so, please list.