Human Animal Bond : Volunteer Form

Name: *
Street *

City:
State:
Zip Code:
Phone:
E-mail Address: *
Comments:
Occupation
Pet Name: *
Type of Animal *
Age
Breed of Animal
Veterinarian Name
Veterinarian Phone
Have you been certified with other pet therapy organizations? (Delta Society, Therapy Dogs, Inc, other military groups?) *
Which Groups?
How long do you plan to be in the Leavenworth/Lansing area?
What are your leisure time interest and hobbies
Do you have any special Skills that might benefit our program? (animal training, languages, computer skills, etc.)
Do you or your pet have any special needs or medical challenges that might require accommodation to be active in HAB?
Attach a Pic for your HAB ID:

Verification Code:
Enter Verification Code: *


* Required