Reading with Rover

Literacy Coach Therapy Dog Application

First Name

Last Name

Street Address

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Phone preference Please indicate your preferred phone number

Email

Dog's name

Breed

Female

Male

Dog's age

Does your dog live with children in the home, or has your dog worked with children in the past?

Is your dog a registered therapy dog?

If yes, what is the name of the national organization you belong to?

How long has your dog worked as a therapy dog?

Name of institution(s) your dog has visited or currently visits:

Are you current on your membership dues?

When is your membership due to expire? (month/year)

Does your dog have a vest or scarf that he/she can wear during library visits?

Does your dog have a collar tag designating him/her as a therapy dog?

Is your dog a Canine Good Citizen?

If no, would you be willing to enroll your dog in a Canine Good Citizen program?

Has your dog had any major health issues recently?

If yes, please explain:

Has your dog had Giardia, worms, mites, lice, ticks or any other parasite within the last 6 months?

If yes, please explain:

Henderson Libraries may require you to obtain fingerprinting. Will you be able to do the required finger printing, if asked? Please note that if your fingerprints don't come back clear, it will be at the discretion of the Henderson Libraries Director as to whether you will be allowed to join the program. If you have any questions about this, please contact the library.

Henderson Libraries keeps a digital library of all Reading with Rover dogs. The photographs are used in educational presentations to public libraries, schools, and other educational institutions about our unique reading program. These photos are also used on our library website and in promotional materials. In addition, children participating in our program receive a story about and photograph of the therapy dog they will be working with. Therefore, we require all volunteers to send us one digital photograph of their dog, and to schedule an appointment for their dog with our photographer for a professional portrait. Are you willing to send us a digital photograph of your dog?

Would you be willing to take your dog to a professional pet photographer (at no expense to you)?

Is there anything else you feel we should know about your dog?

Reading with Rover

Literacy Coach Therapy Dog Application

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