MEMBER APPLICATION

Since Heeling Partners is a 502(c)3 charitable organization, you may make a donation for annual membership. We suggest $20.00, but you may give more or less. We do not turn away anyone for lack of funds.

Please copy/paste and print the membership form shown below. If you need assistance, contact Jacquie Tannenbaum at 970-300-4835 (home), 818-795-3884 (cell), or heelingpartners@gmail.com

Heeling Partners of the Roaring Fork Valley Volunteer Application

Name: ________________________________________________________________

Address: ___________________________________City/Zip:  ____________________

Phone number(s) at which to reach you: ______________________________________

e-mail address: _________________________________________________________

Are you 18 years of age or older?   Yes   No

Note: The above information is used only for Heeling Partners business. Write "NO" on this line _____  if you do NOT want this information shown on the Membership Roster (given only to Heeling Partners members).

How did you hear about Heeling Partners? ___________________________________

If you would like to join Heeling Partners with a dog, please provide the following information:

Dog’s Name: ___________________________________ Male or Female (Circle which)

Breed or Mix: ___________________________________________________________

Birth date or approximate year born: _________________________________________

How long have you had or known this dog? ___________________________________

Have you/this dog been evaluated via the Delta Society?      No    Yes (Delta registration #___________)

Have you/this dog been evaluated via Therapy Dogs, Inc.?  No     Yes (TDInc. registration
#___________)


Please check which of the following you would have an interest and the time in which to participate:
___  visit a school(s) with my dog (week day)
___  visit a hospital with my dog (any day)
___  visit a nursing home/retirement center with my dog (any day)
___  board member (1/month)
___  fundraising (at your convenience)
___  special tasks (i.e. website, brochures, photography, accounting, legal, etc.)
___  sewing dog scarves, jackets, etc.
___  other: _____________________________________________________________

Annual Membership: Heeling Partners is a 501(c)3 charitable organization; we suggest that you make a $20.00 tax-deductible donation for annual membership, but you may give more or less. We do not turn away anyone for lack of funds. Please send your completed application and donation (made out to “Heeling Partners”) to the address below.

Heeling Partners of the Roaring Fork Valley
PO Box 2628      Glenwood Springs, CO 81602
www.heelingpartners.org

Last Update: 10/26/11