Children and Adult Specialty Visits Team Application Your Name Date DateAddress Address Line 2City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip Code Email Phone Number Pet's Name Pet's Breed Pet's Age Pet's Sex MaleFemaleIs your pet neutered/spayed? YesNoDate of Most Recent Rabies Shot Name & Address of current veterinarianHave you completed at least 6 visits to a CAP Adult Care facility? YesNoWhere?Where do you currently visit as a CAP Team?What is the name of the CAP captain at the facility(ies) you visit?Why do you want to become a Children's Program Team?How often does your dog interact with children? Describe the setting and interaction below.How does your dog react to the following.... 1. Close contact with children on the floor or a chair?EnjoyTolerateAvoid2. Hugs?EnjoyTolerateAvoid3. Being touched on face, ears, nose, toes, tail, or feet?EnjoyTolerateAvoid4. Remaining quiet and “settled” long enough for children to interact, (5-10 minutes at a time)?EnjoyTolerateAvoid5. Has your dog ever bitten or nipped an adult or child? YesNoIf “yes”, please explain.6. Does your dog bark at children? YesNo7. Is there any situation that upset or frightens your dog? YesNoIf “Yes” Please explain8. What days might be best for you to volunteer (check all that apply)? MondayTuesdayWednesdayThursdayFridaySaturdaySundayWhat times might be best for you to volunteer (check all that apply)? 9-1010-1212-22-44-5EveningsDo you have any questions or additional information? You will be contacted by Susan Hunt to coordinate your request. You can reach her at 508-341-0658 or sehunt7839@gmail.com
