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 NCTD Volunteer 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:

Volunteer Registration Information

I originally joined NCTD in (month/year)

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

Our team was evaluated as: Predictable Environment Complex Environment

Facility Information

Please indicate where you are currently visiting or would be interested in visiting:

Facility Name	Start Date	End Date	How Often (per month)
Chevy Chase House
Children's House at Johns Hopkins
Faith Baptist Christian School
Holy Cross Hospital
Kessler Adventist Rehabilitation Hospital
National Institutes of Health
Shady Grove Hospital
Sheppard Pratt at Ellicott City
Sibley Memorial Hospital
Other:
Other:
Other:

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.