Thank you for your interest in becoming a Pets As Therapy Visitor.
Enclosed you will find the Pets As Therapy Registration forms which we hope you will print, complete
and return together with a passport sized photograph for each person, along with a clear head and
shoulder photograph of your dog or cat. (Please write your surname and reference number on
reverse of photographs).
Please telephone your Volunteer Area Coordinator, at a reasonable time, details supplied in your
email, to arrange for your pet to be assessed.
On the next page are guidelines which we hope will give you assistance in completing this pack, plus
a check list to confirm all the paperwork is correct for return to the above address. Packs that are
incorrect or incomplete will be returned. This will extend the completion time.
We have taken a great deal of care in planning Pets As Therapy and our objective is to continuously
improve our standards and service. You will be joining a UK wide family of volunteers, who together
with their pets bring their own brand of sunshine to over 145,000 people every single week.
Once registered, you will visit in a Hospital, Home or establishment in your own vicinity and your
commitment depends on the amount of spare time you have available.
We look forward to working together, however should you feel that you or your pet are not quite ready
yet, please return this pack. This will be very much appreciated and does not stop a further
application at a later date. Or why not consider becoming a non-visiting supporter, details available
on request or from our website.
Yours sincerely
The Pets As Therapy Team
N.B. Due to staff levels, completion time is 12
weeks, your understanding is appreciated.
Guidelines for completing the Pets As Therapy Registration Pack
Check List
Please turn over
Registration Form
Application to register a Pets As Therapy pet.
Owner’s details
Please compete all sections in BLOCK capitals. If you are registering more than one
pet, each one should have its own registration and assessment form (please photocopy)
and should have been living with you for a minimum of 6 months.
Security details
This must be completed to keep your details confidential.
Pet Profile
Please complete the profile of your pet. This helps the official Pets As Therapy Assessor
or vet when completing their assessment.
Declaration
That you have read and understood the declaration on Pets As Therapy and agree to
abide by our policies. You will receive a Pets As Therapy Visitors Handbook, which will
cover the scheme more fully. Pets As Therapy reserves the right to offer subscriptions or
de-register volunteers. This decision is final.
Pet Assessment
For Dogs. ONLY a Pets As Therapy trained assessor or a Veterinary surgeon can carry
out an assessment. PLEASE NOTE – Veterinary Nurses may only carry out the
assessment if they have taken part in a Pets As Therapy assessors course and
are on the accredited assessors list. Assessments will not be accepted from anyone
else. Please do not ask the assessor if your pet has passed or failed as acceptance or
rejection will be decided at the Registration Office when all factors have been taken into
account. Pets As Therapy reserve the right to undertake spot temperament checks on
registered Pets As Therapy dogs.
Vets Assessment
In addition to assessing you and your dog as a working team, the assessor is also asked
to complete a form about your role as a volunteer. They will find out about your
understanding of the work of the Charity, your commitment to volunteering and your
general suitability as a volunteer. We feel that this is a key part of the assessor’s role, as
they are often the only person to meet you face to face before you start visiting with the
Charity. The form may be used by us as supplementary information to the character
references that we request for you and is not used to make a definitive decision on your
overall application. If you would like to see a blank copy of the form that the assessor is
asked to fill in, please ask us. Assessors have a copy of this form, but if a vet is
undertaking your assessment, please ask them to contact the Registration Office
on 01494 569130 to obtain the form.
Reference Form
Confidential Reference Requests. Please ensure that you let the referees know they will
be receiving a form and that they should complete it and return immediately. Only these
official reference forms will be accepted. Please supply e mail addresses for speed of
completion. This form also includes a GIFT AID.
PAT APPLICATION CHECK LIST
Please keep the whole pack together and do not separate. Please
ensure that you have enclosed and completed the following:
Please
Tick
1. Assessment sheet completed by assessor
(Do NOT return separately)
2. Correct annual subscription (cheque)
(see subscription details on reverse of Payment Form)
3. Passport photograph of the volunteer(s)
4. Head & shoulders (approx 6" by 4" size) photograph of each pet
5. Details of two references (NOT FAMILY) for each volunteer
who have known you for 5 years or more Names and
addresses only including postcode.
6. A copy of the up to date RECORD of IMMUNISATION issued by a
veterinary surgeon for each pet must accompany this application.
(Original certificates will not be returned unless a stamped addressed
envelope is supplied). No responsibility will be accepted by the charity
for original certificates
7.
If you are a tax payer – Gift Aid certificate
(This gives Pets As Therapy an extra 28p in the £ at no cost to yourself.)
8. If you would like us to acknowledge receipt of this pack
please enclose a stamped addressed envelope.
If you are in any doubt – Please ring the Registration Office for assistance.
Please Note: The Pets As Therapy Charity offer our service to people of all ages and
disabilities. We can not guarantee that you and your prospective PAT pet will be visiting
with children. We ask that volunteers are prepared to visit at an establishment within
their own area with clients of any age.
Failure to supply complete information will result in delays in processing
your application
APPLICATION TO REGISTER A PETS AS THERAPY DOG
Owners Details
Title:
Please complete all sections in BLOCK CAPITALS:
First name:
Surname:
We are unable to
accept applications
from persons under
18 years
Enquiry Ref:
House No./Road:
Town:
Postcode:
NB. Dogs must be
over 9 months old.
Dogs must have
been with their
current owner for
at least 6 months.
County:
Email Address:
Phone number:
Include area code
Ex Directory:
Yes/No
Profession:
Security Details
Your date of birth:
Memorable Name: (or Mother’s Maiden Name)
Pet Profile
1.
2.
3.
4.
a: Dogs Name:
b: Dogs Age in Years:
How long have you owned the dog?
Years:
Months:
Breed or type of dog:
a. Does your dog have a good, reliable temperament with PEOPLE CHILDREN Y
N
b. Does your dog have a good, reliable temperament with OTHER DOGS Y
N
5. Does your dog have any formal training? Y
N If yes please give details: ________________________
6. Has your dog been IMMUNISED against distemper/canine infectious hepatitis/ parvovirus and leptospirosis
within the last 12 months? Y
N
(A dog that has NOT been IMMUNISED cannot be accepted as a Pets As Therapy dog)
DECLARATION
Do you agree that you will at all times:
Make visits with your dog regularly for the benefit of the community, when your dog is accepted as a
registered Pets As Therapy dog?
Abide by the policies and procedures of the establishments you will visit and the Pets As Therapy charity
Maintain and present your Pets As Therapy dog in good health, free from parasites and well groomed?
Accept complete responsibility for your own actions and that of your dog whilst on visits?
Accept that my contact details will be passed only to a Pets As Therapy Area Co-coordinator/Placement
Officer in order to give me support in my Pets As Therapy role. (Please note your contact details will not be passed on to any 3rd party).
Display your Pets As Therapy photo identity badge and that of your pet on any visits made?
Keep your PAT dog on a lead. No long training leads, flexi leads, retractable leads, head collars, check
chains or restraining harnesses allowed. (If your dog is not obedient on a regular lead it isn’t ready to be a PAT dog).
I consent to Pets As Therapy a company limited by guarantee processing my personal data for the purposes of:
Processing my registration application.
Arranging visits from volunteers.
Membership administration.
Sending me information about the work of Pets As
Therapy
Sending me other information which maybe of interest to me
Subscription to or deregistration from the charity will be determined by the charity. Their decision is final.
To the best of my knowledge and ability I hereby certify that I have answered truthfully all the questions in this
application form and agree to abide by the Pets As Therapy code of ethics for therapy dogs as indicated above
and agree to abide by the Pets As Therapy equal opportunities policy.
Owner Signature:
Date:
RETURN TO: PETS AS THERAPY, Clare Charity Centre, Wycombe Road, Saunderton, High Wycombe, HP14 4BF.
Phone: 01494 569130
REFERENCE REQUESTS
Please give below the names and addresses of two people (NOT RELATIVES, PARTNERS OR PARTNERS
RELATIVES) to whom we can write and take up character references. They will need to have known you at
least FIVE YEARS:Application Reference:
Reference 1
Title:
ALL THE FOLLOWING INFORMATION IS ESSENTIAL
First name:
Please note:
Joint subscription will
require two references
per applicant. Please
use a separate sheet of
paper for second
applicant’s referees.
Surname:
i.e. Mr / Mrs / Dr
Relationship to you
Email.:
Address:
Town:
County:
Postcode (Important):
(NOT RELATIVES)
How long have you know this referee:
Reference 2
Title:
ALL THE FOLLOWING INFORMATION IS ESSENTIAL
First name:
Surname:
i.e. Mr / Mrs / Dr
Relationship to you
If you register more
than one dog, please
note that visits can only
take place with one dog
at a time.
Email.:
Address:
Town:
County:
Postcode (Important):
How long have you know this referee:
GIFT AID A TAX CONCESSION FOR CHARITIES
Arrangements allowing charities to reclaim tax on all donations received from tax payers came into force on
6th April 2000. Pets As Therapy can benefit from these arrangements and in order to do so are required to
obtain a declaration from the donor that he/she pays income or capital gains tax.
Please complete the declaration below and return it to us. This will enable us to recover tax on any donations,
including registration fees, that you make to Pets As Therapy in future. Please advise us if your circumstances
change and you cease to pay an amount of income or capital gains tax equal to the tax that we reclaim on
your donations (25 pence for every £1 you give).
I confirm my wish that all donations which I have made since 6th April 2000, or will make in The future, to the charity Pets As
Therapy are to be treated as Gift Aid donations. I confirm that I am a UK taxpayer, paying at least an amount of income or capital
gains tax equal to the tax which Pets As Therapy will reclaim on my donations (25 pence for every £1 given). I will advise Pets
As Therapy if this situation changes.
Signature:
Name/Address:
Date:
Reference:
GIFT AID
PET ASSESSMENT FOR DOGS
Arranging the assessment: Please contact your Voluntary Area Co-ordinator for an accredited assessor who
can assess your dog. All assessors (vets excepted) must have undertaken our training course in order to
assess your dog. Because of the establishments (hospitals and similar) which the dog and volunteer owner will
be visiting and the personal situations of the people they will be meeting, we need to ensure that all animals
are healthy, friendly and entirely suitable to work in these places. Your dog must be assessed on a collar
and static lead; half-check collars are permitted but extendable leads, check-chains and head-collars
are not accepted for the assessment or on Pets As Therapy visits. We may accept harnesses only if
there is a valid medical reason. Please contact the Registrations Office if you require further information
regarding this.
Owner information: The dog needs to have been with its present owner for at least six months and be at
least 9 months of age at the point of assessment. Dogs ‘give’ a lot during their hospital visits and we have
often found that they are very tired and go straight to sleep when they get home. For this reason we feel that
elderly dogs might find the work too much of a strain.
*Joint Subscriptions: NB If your subscription is to be a joint subscription and both parties are to be visiting
an establishment then both parties must be assessed handling the prospective PAT dog.
Acceptance of your dog as a PAT dog: The acceptance or rejection of your dog to become a PAT Dog Will
Not be decided by the assessor at the end of the assessment – Please do not ask your assessor whether your
dog has passed the assessment
Returning the forms: This form will be assessed, along with the other completed forms, at the Registration
Office. To avoid any delays with your application please ensure you send all the necessary completed forms.
Please give this form to the assessor to complete the following sections
VETS: If you are a vet undertaking this assessment, please contact the Registration Office on 01844 345445 to obtain a
copy of the vets assessment form. Thank you for assessing the following dog to become a Pets As Therapy Pet.
(*NB please see note joint subs above)
OWNER AND DOG INFORMATION:
Name of First Volunteer:
Name of Second Volunteer:
Address:
Postcode:
Assessor, please confirm that the dog:
Dog’s pet name:
Is over 9 months of age
Breed or type of dog:
Has been with the owner for at least 6 months
Is the dog a registered assistance dog? If yes, please obtain the volunteer’s permission for the relevant
charities to be contacted. Please ask volunteer to sign here in your presence
ASSESSMENT:
1.
Where did the test take place?
NB: Assessments must not be carried out in the prospective volunteer’s own home
2.
Assessor to describe the initial behaviour of the dog on meeting:
Please tick appropriate answers to the following:
3.
Assessor to confirm whether the dog was presented on a collar and lead (no slip leads,
extendable leads, head-collars, harnesses or check-chains allowed)
Yes
No
4.
Owner to demonstrate relaxed lead walking:
Did not pull at all
Pulled, but only a little
Pulled strongly
5.
Owner to demonstrate control with dog on lead whilst holding a conversation:
Dog required
A few gentle commands were required,
No commands were
repeated commands
but excessive commands not required
required – dog stayed
to stay close
calm beside the owner
6.
Owner to demonstrate grooming of dog’s back, chest, stomach and around tail. Was the dog:
Calm
Excited
Mouthing
Rolling over
Backing away/reluctant
Jumping at owner
7.
Owner to demonstrate restricting the dog by holding his collar and pulling him close
firmly. Did the dog:
Accept readily
Struggle
Escape hold
Mouth owner
Growl
8.
Assessor to stroke and fuss the dog. Was the dog:
Calm
Enjoying it
Excited
Mouthing
Backing away
Jumping up
Pawing you
Indifferent
9.
Assessor to examine paws, ears, hold tail. Did the dog:
Accept readily
Accept reluctantly
Struggle
Escape hold
Rolling over
Mouth you
Growl
10.
Which did you find the most difficult. Please explain why:
Paws
Ears
Hold tail
None
11.
Assessor and volunteer to be sitting down and assessor to offer the dog a small food treat
between closed fingers. Did the dog:
Not take it
Take it gently
Take it greedily
Snatch it so you felt teeth
12.
Assessor and volunteer to remain seated for at least 5-10 minutes and assessor to describe
below what the dog was doing during this time. E.g. did it settle; sit or lie down quietly; bark or
whine; pull away on the lead; nudge or paw the owner or assessor for attention.
13.
Assessor to, without warning, drop an object out of sight of the dog which will make a noise
(e.g. walking stick, book, tray). Did he:
Bark at the source of the noise
Flinch away from object but recover instantly
Pull wildly away from noise and remain fearful
Look towards object and then ignore it
Flinch away from object and remain fearful
Look towards object and investigate
14.
Did the dog:
Need grooming Exhibit bad
breath
Have a dirty
coat
Move well
Appear fit and
healthy
Need its nails
trimmed
15.
Did the dog jump up or paw at either the owner or the assessor? If so, who did the dog jump up
at, or paw and approx. how many times? *delete as applicable below
Number of times
The dog jumped up at the assessor/owner*
The dog pawed the assessor/owner*
Please tell us at what point/s during the assessment the dog either pawed or jumped up
16.
Did the dog exhibit any other behaviours that you’d like to tell us about? For example,
excessive licking, or repeated barking? If so, please explain below
Please note: Some of the questions will not necessarily have right or wrong answers. Several different issues
will be taken into account before a final decision is made. Thank you for assessing this dog.
Owner declaration: I agree that these responses accurately represent my dog’s behaviour during the assessment
Signature:
Assessor Declaration – Please ensure that you have completed all 16 questions and the owner information
above. PLEASE HAND THIS FORM BACK TO THE PROSPECTIVE VOLUNTEER
I have met the dog described overleaf, together with the owner on behalf of Pets As Therapy.
Date:
Certified Assessors
Pets As Therapy Assessor ID. No:
Signature:
Veterinary Surgeons
Name:
Surgery Address and postcode:
Name:
Phone No (including STD code):
Tel. no:
E-mail:
PAYMENT FORM
PAYMENT METHODS
Online Banking
Please see website for details
Cheque / Postal Order
Payable to Pets As Therapy, remember to write your reference number on reverse
SUBSCRIPTIONS
Payment
Payment
Frequency
Amount
Further Information
Visiting Scheme
Registered Volunteer
Annually
£19.00
Joint Registered Volunteer
Annually
£29.00
See factsheets on our website
Single Family
Annually
Joint Family
Annually
£25.00
£35.00
Supporter Scheme
Supporter
Annually
£15.00
Joint Supporter
Annually
£25.00
Club or Society Subscription
Annually
£30.00
If you decide your pet does not have a
suitable temperament to become a
registered dog or cat or that you do not
have the time to commit to visiting an
establishment perhaps you would like to
support the work of the charity by becoming
a
Non
Visiting
Supporter.
These
subscriptions are for individuals, joint
subscribers
or
clubs,
societies,
establishments, schools etc.
ATTENTION
PLEASE MAKE SURE THE POSTAGE IS CORRECT AND YOUR
RETURN ADDRESS IS CLEARLY MARKED ON THE ENVELOPE.
(Recently numerous packs have not been delivered due to incorrect postage)
Data Protection Act (1998) Declaration
Your support is vital to the work we do and we thank you for it. We also respect your privacy and would assure you that
Pets As Therapy fully comply with the Data Protection Act (1998). No personal information held by Pets As Therapy will
be disclosed to any third parties without your written consent. If however, you do not wish to receive any further
communications from us, please tick the box below. Thank you.
I do not wish to receive any future communications from Pets As Therapy
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