Middlesex Health

Pet Therapy Adult Volunteer Application

Thank you for your interest in volunteering as a pet therapy team at Middlesex Health.

Please complete all required fields below to establish your applicant profile and apply for a volunteer position.

Applications are reviewed by our Volunteer Coordinator in a timely manner.

* I AM over the age of 18. I am NOT a High School student.

Application Information

* First name

* Family/last name

* Street Address

Apt/Unit #

* City

* State

* Zip/postal

Phone (Home)

* Phone (Mobile)

* E-mail

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Emergency Contact Information

* Emergency contact

* Phone

* Relationship

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Education Information

Highest Level of Education Completed

Have you graduated?

College/University Name

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Current/Most Recent Employer Information

Please check box if currently employed or retired.

Position Held

Current/Most Recent Employer

Supervisor Name

Supervisor/Business Phone Number

Are you now or have you ever been employed by Middlesex Health ?

If yes, please select your facility below

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Pet Therapy Information

* Certified As a Team

* Date of Certification

* Certification Center

Previous Pet Therapy Experience

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Canine Information

Canine Name

* Date of Most Recent Veterinary Assessment

* Date of Most Recent Rabies Vaccine

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Volunteer Experience

Volunteer source

Do you have any previous volunteer experience? (Please select from one of the choices below)

If YES, please list any current or previous volunteer experiences in the box provided below:

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Daily Availability

Please tell us when you are available. (Check all that apply)

Daily Availability: Monday

Daily Availability: Tuesday

Daily Availability: Wednesday

Daily Availability: Thursday

Daily Availability: Friday

Daily Availability: Saturday

Daily Availability: Sunday

* Start Date

* Please state your reason(s) for volunteering:

Community Service Requirement

If yes, please state the number of hours you need to complete:

If yes, select the date that the community service needs to be completed by:

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Applicant Statement

Please check the box below to acknowledge and agree with the following statements:

I understand incomplete applications will not be considered for processing.
I understand that documentation of proof of vaccination of measles, mumps and rubella (MMR) vaccine or laboratory evidence of immunity, proof of vaccination of 2 doses of the Varicella vaccine (vaccine for chicken pox) or laboratory evidence of immunity or history of chickenpox based on healthcare provider diagnosis, and a Tuberculosis Screening results via either a 2-step TB (PPD) skin test [If positive, chest X-ray is required], or Quantiferon Gold (preferred) will be required to volunteer with Middlesex Health.
I understand that a flu vaccine is required in season.
I understand that I will provide a copy of my canine's vet records and pet therapy certfication.
I agree to abide by the policies and regulations of Middlesex Health and the Volunteer Services Department and to participate in orientation and training required by Middlesex Health.
I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.
I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the Director of Volunteer Services to the best interests of the hospital.
I authorize Middlesex Health to take my photograph in relation to my volunteer position.

* I certify that the facts set forth in this application are true and complete to the best of my knowledge.

* I understand and agree that submitting this application form does not automatically register me as a Middlesex Health Volunteer.

* Typing in your name confirms your signature.

* Application date

Thank you for submitting your application. A confirmation message has been sent to your email.