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Name of Professional Dog Owner: _________________________________________
Name of Professional Dog Handler: ________________________________________
Name of Professional Therapy Dog: ________________________________________
Building in which therapy dog will work: ______________________________________
Therapy Dog and Handler's Certification Date: ________________________________
Name of Certifying Organization: ___________________________________________
Date for Re-Certification: _________________________________________________
Emergency Contact Names and Phone Numbers in Case of Issue with Therapy Dog:
1. ______________________________________________________________________
2. ______________________________________________________________________
Veterinarian Contact Information:
Name: ______________________________________ Phone: ______________________
Dates Regarding Therapy Dog's Care:
Date of Birth: _________________ Age: _______ Last Health Check: _________________
Annual Worm Check: ______________ Parvo/Distemper: ______________ Rabies: __________________
Note: Five-way Parvo/Distemper (DHPP) and rabies vaccinations shall be updated every three years. Dogs less than one year of age or receiving vaccinations for the first time shall receive a follow-up in one year with vaccinations every three years thereafter. Verification that preventative parasite control (fleas and ticks) as well as heartworm medication is given year-round.
Owner's Signature: ________________________________________ Date: ________________________
Adopted: 8/17
Reviewed: 4/18; 6/21; 2/24
Related Policy: 604.2; 604.2-E1