Training/Screening Registration Form

Please do one of the following:

Fill the form out on your computer and then print a paper copy or
Make a paper copy of this page and PRINT the information clearly

Name(s):

(If under 18 years old, please specify age)

Address:

Street:
Apt./P.O.:
City:	State: Zip Code:

Home Phone:

E-Mail Address:

Quantity	Training/Screening	Date	Cost	Totals
	NCTD Volunteer Training		$65/person	$
	NCTD Therapy Dog Training Course		$95/animal	$
	NCTD Team Screening		$20/team (No charge for active NCTD teams)	$
TOTAL COST:				$

For accounting purposes, please send separate checks for each different activity.. Thank you for your assistance!

All fees are non-refundable

No Yes:

I am applying for the "Gandalf Fund" for financial assistance. (If you apply, you must submit an application letter. The NCTD Board of Directors will review all applications, and their decision will be final.)

If you are registering for either the NCTD Therapy Dog Training Course or the NCTD Team Screening, please complete the following (for each animal):

Animal's Name:	Type/Breed: Age:
Gender:	Male Female Intact/Altered: Intact Altered

I understand that I assume all responsibility of any and all actions of my animal. I also understand that NCTD is not liable for the action of any other animal in the class.

Signature: _____________________________ Date: __________________________

Send the completed signed form along with check(s), payable to NCTD, and a copy of a current rabies certificate for each animal to:

Jack Quarantillo
Registrar
National Capital Therapy Dogs, Inc.
9514 Dunbrook Court
Montgomery Village, MD 20886