Club Membership Registration Form

Therapy Animals Unleashed

Annual Membership/Renewal Form
Membership*

New Member TeamRenewal
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Call Name of Dog*
Breed (or Mix)*
Color and Markings*
Microchip or Tattoo #
Sex*
Spay or Neuter*
Veterinarian *
Rabies Vaccination # and Expiration Date*
Date of Last Veterinary Exam@*
Member handler of record understands and agrees to the following: (all must be checked)*

I am responsible for the actions of my pet at all times; this includes financial and physical injuryI understand we are a therapy dog team an at no time shall I represent us as a Service Dog TeamI understand my dog and I do not have public access privileges and shall not try to exercise anyI understand we represent Therapy Animals Unleashed and will conduct ourselves appropriatelyI shall advocate for my dog on all visits, and at all times, so that s/he is not put intve rI will contact Therapy Animals Unleashed in the event of any incident that should occur while on a visit to any facility within 48 hours and shall fill out the online incident reportI will make sure my dog (and I) is clean and groomed for all visitsI will make sure my dog is free from internal and external parasitesI give Therapy Animals Unleashed permission to use photographs of me and/or my dog for the purposes of promotion or educationI have read and agree to all Therapy Animals Unleashed policies, guidelines and regulations, including revisions
I understand the following conditions must be met for insurance coverage to be effective (all must be checked)*

Membership dues must be currentI am acting as an animal-assisted interaction volunteer teamI am not using the dog in the course of my normal employment*My dog is on a leash no more than 4 feet in lengthOnly the Handler on Record is in control of the dog at visitsState required vaccinations are currentI am not a registered/certified/member team of any other therapy related organizationI am 18 years of age or older (anyone between 11-17 is a junior member, requiring a JR application)
Signature*

Clear
*additional insured coverage may be necessary

@ A veterinary signature form is required to be on record
Should be Empty:

Therapy Animals Unleashed