MCOA WORKING DOG CERTIFICATE:

THERAPY DOG VERIFICATION

Dog's Name: Date of Birth:
AKC Number:  
Owner(s) Name:  
Address:  
Phone:  
Date Dog accepted
with Therapy Dogs International:		 TDI Membership Number:

ACTIVITY LOG:

Date
DateName & Address of Institution Phone Contact Person # of Patients visited Signature of Contact
1.          
2.          
3.          
4.          
5.          
6.          
7.          
8.          
9.          
10.          


Please attach a copy of your Therapy Dogs International membership card listing your dogs name and TDI ID number.