National Capital Therapy Dogs, Inc.
P.O. Box 234
Highland, Maryland 20777
301-585-NCTD (6283)
http://www.nctdinc.org
E-mail: info@nctdinc.org

NCTD Volunteer Team Profile

If you are a Delta Pet Partner and would like to visit at one or more NCTD facilities, please fill out the following form.

Please complete one form for EACH handler and animal team. If you would prefer, you can print this page, fill it out by hand (please PRINT the information clearly), and mail it to:

National Capital Therapy Dogs, Inc.
Attn: Director of Volunteer Services
P.O. Box 234
Highland, MD 20777

In addition, please send a picture of you and your teammate, either electronically to michelle@nctdinc.org, or mail it to the above address.

General Information

How did you find out about us? (Check all that apply.)
Website Brochure Referral Client Magazine/Newspaper Article
Other: (specify)

Volunteer Information

Name:	DOB:
Address:
City:	State: Zip Code:
Home Phone:	Work Phone: Other Phone:
Fax Number:	E-Mail Address:
Emergency Contact (name):	Phone:

Animal Information

Animal's Name:	Breed: DOB:
Sex:	Male Female Intact Altered
Veterinarian's Name:	Phone:
Address:

Pet Partner Registration Information

I originally joined NCTD in (month/year)

I became a Pet Partner in (month/year)

My most recent (re-)certification was (month/year)

My Pet Partner Registration number is:

Our team was evaluated as: Predictable Environment Complex Environment

Facility Information

NCTD teams visit around 20 facilities in the Washington/ Baltimore area, including major hospitals, assisted-living facilities, hospices and shelters. NCTD teams also visit schools and public libraries under the R.E.A.D. program to strengthen children's reading skills. These facilities offer a wide range of location, schedules and visiting experience to suit most volunteers' requirements. A full listing of these facilities can be found on NCTD's Web site (NCTDinc.org). If you are interested in visiting any of these facilities, you may wish to contact John Burrows, our Director of Facilities (ja.burrows@comcast.net or 301.840.8046) to discuss which facility might be the best fit for you.

I give National Capital Therapy Dogs, Inc. permission to publish the following information on NCTD's Website (http://www.nctdinc.org):

Check all that apply:
Name
Phone Number
E-Mail Address
Animal's Name
Photo you submit for Web Site
Facilities you visit
None of the Above

Remember to submit one form for EACH handler and animal team.