Please telephone your Volunteer Area Coordinator, at a reasonable time, details supplied in your , to arrange for your pet to be assessed.

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1 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 , 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.

2 Guidelines for completing the Pets As Therapy Registration Pack Check List Registration Form Owner s details Security details Pet Profile Declaration Pet Assessment Vets Assessment Reference Form Please turn over Application to register a Pets As Therapy pet. 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. This must be completed to keep your details confidential. Please complete the profile of your pet. This helps the official Pets As Therapy Assessor or vet when completing their assessment. 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. 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. 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 to obtain the 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.

3 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

4 APPLICATION TO REGISTER A PETS AS THERAPY DOG Owners Details Title: Surname: House No./Road: Town: Postcode: Phone number: Profession: First name: Address: Please complete all sections in BLOCK CAPITALS: Include area code Enquiry Ref: County: Ex Directory: Yes/No We are unable to accept applications from persons under 18 years NB. Dogs must be over 9 months old. Dogs must have been with their current owner for at least 6 months. Security Details Your date of birth: Memorable Name: (or Mother s Maiden Name) Pet Profile 1. a: Dogs Name: b: Dogs Age in Years: 2. How long have you owned the dog? Years: Months: 3. Breed or type of dog: 4. 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 3 rd 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. Membership administration. Arranging visits from volunteers. 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:

5 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: i.e. Mr / Mrs / Dr Relationship to you Address: Reference 2 Title: i.e. Mr / Mrs / Dr Relationship to you ALL THE FOLLOWING INFORMATION IS ESSENTIAL First name: ALL THE FOLLOWING INFORMATION IS ESSENTIAL First name: Surname: .: Town: County: Postcode (Important): How long have you know this referee: Surname: .: Please note: Joint subscription will require two references per applicant. Please use a separate sheet of paper for second applicant s referees. (NOT RELATIVES) If you register more than one dog, please note that visits can only take place with one dog at a time. 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 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 6 th 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: Date: Reference: GIFT AID Name/Address:

6 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 to obtain a copy of the vets assessment form. Thank you for assessing the following dog to become a Pets As Therapy Pet. OWNER AND DOG INFORMATION: Name of First Volunteer: Address: Postcode: Name of Second Volunteer: Assessor, please confirm that the dog: Dog s pet name: Is over 9 months of age (*NB please see note joint subs above) 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 repeated commands to stay close A few gentle commands were required, but excessive commands not required No commands were required dog stayed calm beside the owner

7 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 Rolling over 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 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

8 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 The dog jumped up at the assessor/owner* Number of times 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: Name: Tel. no: Signature: Veterinary Surgeons Name: Surgery Address and postcode: Phone No (including STD code):

9 PAYMENT FORM PAYMENT METHODS Online Banking Cheque / Postal Order Please see website for details Payable to Pets As Therapy, remember to write your reference number on reverse SUBSCRIPTIONS Payment Frequency Payment Amount Further Information Visiting Scheme Registered Volunteer Annually Joint Registered Volunteer Annually Single Family Annually See factsheets on our website Joint Family Annually Supporter Scheme Supporter Annually Joint Supporter Annually Club or Society Subscription Annually 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 Ver:20/01/2016r3