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Giving & Volunteering

Volunteering: Angel Dog Program

Name

Date of Birth

Address

City, State, ZIP

Home Phone

Work Phone

Cell Phone

Email Address

Best day(s) and time(s) to contact you

Emergency Contact Name

Emergency Contact Phone

How did you hear about Madonna's Angel Dogs Program?

EMPLOYMENT HISTORY

Are you presently employed

Are you retired

Current Employer

Position

Phone

Length of Employment

Have you been (or are you) employed at Madonna?

If yes, in what position?

Name of any relative presently working at Madonna

Relationship

Department

Past Employer

Position

Phone

Length of Employment

About Your Dog:

(If you plan to use more than one dog in the Angel Dogs program, please provide this information for all dogs, using an additional sheet of paper which may be attached to this application.)

Name

Breed

Age

Sex

Male
Female

Have you begun the process to have your dog certified?

If yes, please explain where you are in the process.

Has your dog had any formal obedience training?

If yes, where?

Level completed?

Why do you believe your dog is a suitable candidate to be a therapy dog?

Is your dog on regular monthly flea preventative/treatment?

If yes, which product?

REFERENCES

(Please provide complete addresses for all references listed)

Please list one (1) personal and one (1) business or volunteer-related character reference, not related to you, whom we may contact:

Reference #1 Name

Phone

Relationship

Address

City, State, ZIP

Reference #2 Name

Phone

Relationship

Address

City, State, ZIP

References #3 Name

Phone

Relationship

Address

City, State, ZIP

BACKGROUND INFORMATION

(Please answer the questions below as completely as possible.)

Have you ever been convicted of a felony

If yes, please describe

Have you ever been convicted of abusing, neglecting, or mistreating individuals or animals?

GENERAL QUESTIONS

What foreign language do you speak fluently

Name (first name only) as you would like it to appear on your name tag (please print)

About Your Interest in the Angel Dogs Program:

1. Describe why you are interested in becoming an Angel Dogs volunteer visitor

2. What personal and/or spiritual gifts or strengths do you believe you have that would help you serve as an Angel Dogs volunteer?

3. In what ways do you think you would personally benefit from your training and service as an Angel Dogs volunteer visitor?

4. Please tell us about any experience(s) you may have (employment history, volunteer work, education, personal experiences) which you think may be helpful to you as an Angel Dogs volunteer visitor

5. Hobbies and personal interests

6. From your current understanding of what it means to be an Angel Dogs volunteer visitor, what do you think would be the difficult or challenging aspect(s) of this role for you?

7. How would people who know you describe the way you relate to others?

Please read and submit the form

The information I have provided in this application is true and complete to the best of my knowledge. I will support Madonna's mission and core values, and all rules governing the Angel Dogs program during my volunteer service at Madonna. I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, residents or staff. My services and those of my certified therapy dog will be donated to Madonna Rehabilitation Hospital without contemplation of compensation or future employment and are given for humanitarian and charitable reasons.

Madonna Rehabilitation Hospital
5401 South St. • Lincoln, NE 68506
Phone: (402) 489-7102 • Toll-Free: (800) 676-5448
E-mail: info@madonna.org