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 Update

Please complete one form for EACH handler and animal team. Please fill in your name and animal's name and all changes to your information.

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

Volunteer Information

Name:
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:
Intact  Altered
Veterinarian's Name: Phone:
Address:

Pet Partner Registration Information

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

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:

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

Copyright © 1997-2007 National Capital Therapy Dogs, Inc. 
A 501(c)(3) non-profit organization