Volunteer: Angel Dog Program

Which location are you applying to be a volunteer?

•    Lincoln Campus
•    Omaha Campus

First Name *

Last Name *

Birthday *

Address *

City, State *

Zip Code *

Phone *

Email *

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

Emergency Contact Person *

Emergency Contact Phone *

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

Are you currently employed? *

•    Yes
•    No

Are you retired? *

•    Yes
•    No

Current Employer *

Employer's phone number *

Position *

Length of Employment *

Have you ever been employed by Madonna Rehabilitation Hospitals? *

•    Yes
•    No

If yes, in what capacity?

Do you have any family members who are employed by Madonna? *

•    Yes
•    No

If yes, please specify.

Past Employment

Past Employer *

Past Position *

Length of Employment with Past Employer *

Past Employer Phone Number *

About Your Dog

Dog's name *

Breed *

Age *

Sex *

•    Male
•    Female

Have you begun the process to have your dog certified? *

•    Yes
•    No

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

Has your dog had any formal obedience training? *

•    Yes
•    No

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? *

•    Yes
•    No

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 whome we may contact:

First Reference Name *

Phone *

Relationship *

Address *

City, State *

Zip Code *

Second Reference Name *

Phone *

Relationship *

Address *

City, State *

Zip Code *

Third Reference Name *

Phone *

Relationship *

Address *

City, State *

Zip Code *

Background Information

Please answer the question below as completely as possible.

Have you ever been convicted of a felony? *

•    Yes
•    No

If yes, please describe

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

•    Yes
•    No

General Questions

What foreign language do you speak fluently? *

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

About Your Interest in the Angel Dogs Program

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

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

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

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.

Hobbies and personal interests *

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?

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 Hospitals without contemplation of compensation or future employment and are given for humanitarian and charitable reasons.

Volunteer Signature *

Date *

Submit