All Registrations Forms (Without Fee) 1Registration2Proof of Vaccination3Application for Membership Testing RegistrationName of Handler* First Last Handler's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Handler to be Tested(all handlers must be 14 or older and only one additional handler may be certified at the same time) First Last Dog's Name*(Please fill out a separate form for each individual dog being tested) Dog's Age*(Dogs must be at least 1 year-old) Breed of Dog* Where would you like to volunteer once you and your dog become a TDV-certified team?If you do not know of a specific facility, what would you like to do with your certification?All certified teams are expected to become active volunteers with TDV (i.e., TDV does not certify dogs solely for community/school projects or short-term community service requirements.)Why you do want to become involved with Therapy Dogs of Vermont?How did you learn about Therapy Dogs of Vermont?Raw Meat Diet* I certify that my dog is not on a raw meat diet(therapy dogs must not be on a raw meat diet per TDV guidelines)6 Months Consent* I certify that I have had/been living with my dog for at least 6 months before the testing date(Dogs must be owned by/living with the handler for at least six months before being tested.) Certification Rules & Policies*Please read through and agree to the Certification Rules & Policies before proceeding. I agree to the Certification Rules & Policies.WAIVER/RELEASE OF CLAIMS: Therapy Dogs of Vermont - for Accidental Injury*I hereby certify I am aware of all the inherent dangers of handling dogs (mine and others) and of the basic safety rules for activities connected therewith. I understand that it is not the purpose of Therapy Dogs of Vermont to teach safety rules, obedience or handling of dogs and I’m familiar with Therapy Dog of Vermont Policies for handlers and dogs. I understand and guarantee that while I am participating in my three (3) visits prior to membership, I am responsible for any incident that might occur, and absolve and agree to hold harmless Therapy Dogs of Vermont from any liability. I also understand and agree that neither Therapy Dogs of Vermont or its officers, directors, members or agents may be held liable in any way for any occurrence in connection with said activities which may result in injury, death or damages to myself, family, or my dog. In consideration of being a member of this organization I hereby personally assume all risks which may befall me while I am engaged in this activity whether foreseen or unforeseen and further hold harmless the above mentioned entities and persons from any claim by me, or my family or any other party arising out of my participation in this activity. I further state that I am of lawful age and legally competent to sign this affirmation and release, which I understand. I have fully informed myself of the contents of this affirmation and release by reading it before I signed it. I assume my own responsibility of physical fitness and capability to perform under the normal requirements of this activity. I understand that TDV 3rd party liability insurance applies only when a currently registered therapy dog is participating in a TDV sponsored non-profit activity. I have read and agree to abide by TDV Policies during testing, during evaluations, and while volunteering. Additionally, I will indemnity/hold harmless Therapy Dogs of Vermont from any incident that occurs regarding this dog after testing. I agree to the waiver/release of claims.First Choice for Test Location*WillistonWells RiverExact location to be provided when we confirm your application. Please select the Vermont region that best applies to you.First Choice for Test Date in WillistonJuly 22, 2023(Testing) 10:00amJuly 22,2023 (Testing) 12:15pmSeptember 23,2023(Testing) 10:00amSeptember 23, 2023(Testing) 12:15pmOctober 21,2023 (Testing) 10:00amOctober 21, 2023 (Testing) 12:15pmSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenFirst Choice for Test Date in Derby LineApril 25, 2020 12:00 PMJuly 18, 2020 12:00 PMSeptember 19 2020 12:00 PMSites will be determined at a later date. Please select the Vermont region that best applies to you.First Choice for Test Date in Wells RiverMay 21, 2023 (Testing) 10:00amSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenFirst Choice for Test Date in LebanonJune 20, 2020 1:00 PMNovember 7, 2020 1:00 PMSites will be determined at a later date. Please select the Vermont region that best applies to you.View Testing DatesSecond Choice for Test LocationWillistonSecond Choice for Test Date in WillistonJuly 22,2023 (Testing) 10:00amJuly 22, 2023 (Testing) 12:15pmSeptember 23, 2023 (Testing) 10:00amSeptember 23, 2023 (Testing) 12:15pmOctober 21,2023 (Testing) 10:00amOctober 21, 2023 (Testing) 12:15pmSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenSecond Choice for Test Date in Wells RiverMay 21, 2023 (Testing) 10:00AMSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenSecond Choice for Test Date in LebanonSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenSecond Choice for Test Date in Derby LineApril 25, 2020 12:00 PMJuly 18, 2020 12:00 PMSeptember 19, 2020 PMSites will be determined at a later date. Please select the Vermont region that best applies to you.View Testing DatesRegistration Fee Price: Proof of VaccinationBy checking off the items below, you acknowledge that you understand each item, comply, and attest each to be true. I uploaded my dog's current rabies vaccination certificate to the TDV portal when I applied for testing. I will keep my dog's rabies vaccination current during the certification process and as a member. I will be prepared to provide rabies certificate on demand at any time during the certification process and when I am making visits as a member. Please note that a rabies tag is not acceptable documentation. During the evaluation phase and as a TDV member, I will not take the dog on visits if he/she is not feeling well or has any symptoms of illness. I will ensure the dog is clean and free from parasites when making visits. I certify that the dog is not on a raw meat diet. I certify that the dog is not a hybrid, or wild canine cross (i.e., wolf hybrid, coyote hybrid, etc.). I certify that should the dog experience any changes in behavior (fear, aggression, etc.) or health conditions (blindness, loss of hearing, pain, etc.) that I will consult TDV and, if necessary, retire the dog from therapy dog work. Attach Rabies Vaccination Certificate*Max. file size: 50 MB. Application for MembershipName* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cell Phone*Primary Email* Alternate Email* Business/Occupation* Name of Dog* Male or Female?* Male Female Breed/Mix* Bandana Size* Large Small Consent* I certify to the following policy.I certify that I have read and understand all of the policies and insurance coverage as set forth by Therapy Dogs of Vermont (TDV). I certify that I have not falsified anything about myself or my dog. I agree to abide by all policies while participating in TDV sponsored events and TDV visits. I further agree to abide by the policies of any facility where I may be working my dog under the name of Therapy Dogs of Vermont. TDV may revoke my certification and membership at any time if policies are not followed or the dog poses any perceived threat. I certify that I am applying for TDV membership solely so that I can volunteer with my dog to make therapy dog visits in the community. Certification may not be used to gain rights typically reserved for service dogs, such as access to non-dog friendly establishments, airlines, housing that restricts dogs, etc. I certify, to the best of my actual and constructive knowledge, that the dog I am presenting to TDV for certification has not been involved in an aggressive incident which has caused physical harm to a human or another dog(s); that the dog has never been used for dog-to-dog fighting, trained to attack humans, or has engaged in any other activity that would pose a threat to humans or other dogs; and that the dog is not a probable source of danger.EmailThis field is for validation purposes and should be left unchanged.
