Applications are accepted up until the Thursday evening before the upcoming clinic/test. Name 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 Handler's Email* Handler's PhoneUpload your COVID-19 Vaccination Card* Drop files here or Select files Max. file size: 50 MB. All registrants must have received the following: 2 COVID SHOTS (Moderna & Pfizer) OR 1 COVID SHOT (Johnson & Johnson). *Boosters are encouraged but not requiredAdditional 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* Upload Your Dog's Rabies Vaccination*All dogs must be up to date for rabies vaccination at the time of the evaluation.Max. file size: 50 MB.Where would you like to volunteer once you and your dog become a TDV-certified team?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)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?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 WillistonDecember 11 (TESTING) 10amDecember 11 (TESTING) 12:30pmSites 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 RiverOctober 29th 2022, 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 WillistonDecember 11 (TESTING) 10amDecember 11 (TESTING) 12:30pmSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenSecond Choice for Test Date in Wells RiverDecember 7,2019 10:00AMMarch 7, 2020 10:00 AMAugust 8, 2020 10:00 AMOctober 17, 2020 10:00 AMDecember 5,2020 10:00 AMSites will be determined at a later date. Please select the Vermont region that best applies to you.HiddenSecond 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.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 DatesHow did you learn about Therapy Dogs of Vermont?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.Certification Rules & Policies*Please read through and agree to the Certification Rules & Policies before proceeding. I agree to the Certification Rules & Policies.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.) Registration Fee Price: Please proceed to PayPal to pay the registration fee using the button below. No PayPal account required. Your registration will not be valid until we have received payment. Thank you!CommentsThis field is for validation purposes and should be left unchanged.
