First Responder Therapy K9 Teams

First Responder Therapy K9 Teams

The 100 Club of Illinois connects resources for first responder emergency response and refers departments to available resources during times of need. To be considered for referral or requests of first responder therapy K9 teams, please complete this form. The details requested in this form are intended to provide us as much information to know the handler and K9 needs to best match and place teams at various events. Thank you for taking the time to complete this form and we look forward to working with you in the future!
Handler Information
Handler Name*

First NameLast Name
Handler Rank/Position*
Are you a:*

Sworn member of your departmentCivilian member of your departmentOther
Handler Email*
example@example.com
Handler Direct Phone Number (cell phone if available)*
Please enter a valid phone number.Format: (000) 000-0000.
If the above number is a cell phone number, can we text you for requests?*

YesNoThat is not a cell phone numberOther
Can your name, email address, and phone number be shared by 100 Club staff with department members seeking referrals for Therapy K9 Teams?*

YesNoOther
Handler Department*
Department Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What other wellness related role(s) do you have within your department?*

Peer Support MemberPeer Support CoordinatorWellness CoordinatorWellness Trainer (list topics below)No other wellness roles at this timeOther
K9 Information
K9 Name*
K9 Breed*
K9 Gender*

MaleFemale
K9 Size*

Small: 7-15 lbsMedium: 15-30 lbsLarge: 30-65 lbsXLarge: 65+ lbs
K9 Birthday (Month, Date, and/or Year if known)*
What year did your K9 begin to serve with you? *
What trainings and certifications has this K9 completed?*
What ongoing training do you maintain with your K9?*
Where has their therapy K9 training been completed?*
Does this K9:*

Live at home with their handler when not on dutyLive at the departmentOther
Please share a photo of your K9!*

Cancelof
Team Information

Help us get to know you and what circumstances you thrive together as a team!
Is your K9 Department owned?*

YesNo
Is your Department supportive of you responding to provide outside agencies support if your schedule allows?*

YesNoOther
Which type(s) of events would you respond well to?*

First Responder Family Days: happy, social outings with kids and familiesCritical Incident Response: serious, typically smaller gatherings at departmentsLine of Duty Death Wakes & Funerals: somber, large attendance gatherings that could include loud noises such as sirens, 21 gun salute, fly overs, etc.First Responder Benefits or Community Days: energetic large or small scale events that may include families and kidsOther
Is there any training or education that you are looking for to be better equipped to serve in other capacities?
What duration(s) of response time/K9 capacity work for your team?*

1-3 hours4-6 hours7+ hoursOther
Are there working elements that you or your K9 are NOT best to respond to (kids, elderly, loud noises, crowds, etc.)? Please explain.*
Is your K9 Team prepared to respond (select all that apply):*

As a solo K9 TeamWith other K9 TeamsOther
Do you have any other response preferences?
What social media handle(s) are best to follow and tag your K9 Team?
Facebook:   Type a label
Instagram:  Type a label
Twitter:   Type a label
Other:   Type a label
We love to highlight the work you do as a K9 Team on social media. Would you like to fill out some extra questions we could use answers for to post about your team?*

YesNo
What is your K9's favorite activity to do off duty?
What is your K9's favorite snack?
What is your K9's favorite toy?
What is one word to describe your K9?
What is one word to describe your K9/handler connection?
What is something unique about your bond?
What is your proudest moment of your K9 or a time that stands out to you that they made a significant impact on the first responder community? (Answers may be adjusted to keep incident details confidential)
What is your K9's coolest trick and/or command?
Share with us some of your K9's nicknames, if any.
What are your department's social media handles for us to tag you? (We already have your K9's above!)
Are there photos outside of the profile picture submitted above that you would like us to consider using? (Please only share photos we have permission to use and/or that do not show identifying details of a sensitive visit.)

Cancelof
Is there any other information you would like to share for a fun highlight post?
Please review the regional map above and select the region(s) you're comfortable traveling to:*

NortheastNorthwestWest CentralCentralEast CentralSoutheastSouthwestAll of the above
Would you be ok with having your K9 Team listed on our Provider Network webpage as an available resource for first responder needs?*

YesNoOther
Is there any other information you would like to share with us?
What other Therapy K9 Teams do you know of? Please leave their names/department/email address.
Thank you for taking time to complete this form. We truly appreciate it and the work your K9 Team does serving the first responder community!
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First Responder Therapy K9 Teams

Handler Information

K9 Information

Team Information

Thank you for taking time to complete this form. We truly appreciate it and the work your K9 Team does serving the first responder community!