Empower Therapy / Facility Dog & Handler Application Form
If you have a great natured dog and would like more information about joining our therapy team as a therapy / facility dog and handler team, please fill out this application form. We will be in touch within a week of receiving this completed application.
Handler Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Date of Birth:
*
-
Day
-
Month
Year
Date
Gender:
*
Where did you hear about us ?
*
Why do you want to join our Therapy Team ?
*
Do you hold any of the following ?
*
Blue Card (QLD)
Working with Children's Card (NSW)
None
Please upload your current card
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If you are unable to upload at the moment, please email through to therapy@empowerassistancedogs.org.au when you have access to it.
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What are you wanting to join up as:
*
Therapy Dog and Handler Volunteer
Facility Dog and Handler Volunteer
Both
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Dogs Information
Dogs Name:
*
Dogs Breed:
*
Dogs Age:
*
Please note: We are unable to accept dogs that are 10years of age or older.
Dogs Sex:
*
Male Desexed
Male Entire
Female Desexed
Female Entire
How old was your dog when you got it:
*
Where was your Dog acquired from:
*
Has your dog had any training:
*
Yes
No
What type of training, where and for how long:
Has your dog ever been scared or had any incidents of needing to escape or protect itself from people or children?
*
Yes
No
Please explain the circumstances.
Has your dog ever been involved in any incidents or been attacked by another dog?
*
Yes
No
Please explain the incident and also whether this has had an affect on your dog’s behaviour?
Does your dog have any medical conditions i.e. arthritis:
*
Have you got a health report from your vet stating your dog is in good physical condition:
*
Yes
No
Please upload the report from your vet
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Choose a file
If you are unable to upload at the moment, please email it to therapy@empowerassistancedogs.org.au
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Has your dog ever shown a high suspicion or avoidance or unsure behaviour of men, women, children or people of different races?
*
Yes
No
Please provide details:
Have you or your dog ever done something similar before e.g. Visited hospitals, schools etc:
*
Yes
No
What types of places or environments have you visited:
How often are you wanting your dog to work within the facility: daily, weekly, fortnightly, monthly, other (please state)
Name of the facility where the dog will be working:
List all the ways your dog meets or greets people:
*
Does your dog do any tricks?
*
Any additional comments or information you think we should know:
Empower Assistance Dogs & Empower Therapy Dog Team holds the right to decline registrations they deem unsuitable. Volunteer roles are advertised and filled based on the needs of the organisation.
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