Handler’s Name: ________________________________ Phone____________________________
E-Mail: ________________________________________________________________________
Address: _______________________________________________________________________
City __________________________________________________ State ______ Zip Code______
Dog’s Name(s): __________________________________________________________________
Breed/mix: ______________________________________________________________________
Dog’s Age ____________ Sex – M F Neutered Spayed
National Therapy Dog Organization that you are registered with: ______________________________
Area of Interest: (Type of facility that you’d be interested in visiting):
___ Nursing home ___ Rehab facility ___ Reading Program
Are you interested in participating in the Books & Barks Reading Partners Program? _______________
Questions, concerns, comments: ______________________________________________________
_______________________________________________________________________________
Waggin’ Hearts annual dues: (please check the one you are applying for)
___ Full Membership – Visiting Team –$20.00. (You must belong to a national therapy dog organization that supplies you and your dog with insurance.) You must send in a copy of your current membership card from the organization providing your insurance, with this membership form.
___ Supporting Membership – $20.00, non-visiting individual – not registered with a dog. Not eligible to do visits or events with a dog.
___ Family Membership – $30.00. Please state whether there is a visiting team within the family. Only the person registered with the dog may do visits or functions with a dog.
Make checks payable to & mail it and this application to:
Waggin’ Hearts Therapy Dogs
PO Box 11
Sperryville, VA 22740
*** Be sure to include a copy of your current membership card from the national therapy dog group you are registered with, copy of your dog’s vaccination record & rabies certificate***
Once all of your paperwork and money is received, you will receive a membership card and be considered a member of Waggin’ Hearts Therapy Dogs.