Booker Willoughby Service Award Application

The purpose of this award is to recognize organizational excellence in training, utilizing and caring for service dogs. Based on the following application, three organizations will be recognized based on their demonstration of excellence in one of three areas: Educational Programs, Service Animal Programs, and Medical Care Programs. Award recipients will be honored at the Human Animal Bond Symposium, Friday May 3rd, 2013 at Virginia Tech in Blacksburg, Virginia. The Center for Animal Human Relationships (CENTAUR) will pay travel and one-night accommodation expenses for one representative from the organization. Completed applications must be postmarked by 20 February 2013 and recipients will be notified by 1 April 2013.

Organization Name:

Primary Point of Contact Name:

Mailing address:

Email address:

Website:

Phone:

Fax:

Check award category in which you are applying. You may select multiple categories that apply to your organization:

o Educational Programs

o Service Animal Programs

o Medical Care Programs

What kind of service does your organization provide? Select all that apply:

o Animal assisted activities

o Animal assisted therapies

o Service Dogs

o Guide Dogs

o Hearing Dogs

o Medical and wellness care

o Other:

Years active:

Primary source of funding:

Number of staff:
Number of volunteers:

Number of animals currently active in the organization:

Number of new service animals trained or enrolled per year:

Number of clients served per year:

Mission statement (100 words or less):

Please provide a short answer for each of the following questions in 100 words or less; you may mark N/A if the question does not pertain to your particular program:

1. Describe the target population you service.

2. Describe the training and screening process utilized for your animals.

3. How do you ensure the health and welfare of your animals?

4. How have you educated the public about your services?

5. Do you participate in research? If so, what have you accomplished?

6. How has your organization impacted the community?

7. What makes your organization different from other similar organizations?

Please submit this completed application along with an overview brochure or pamphlet of your organization that contains a logo or pictures that represent your organization.

Send all materials postmarked by February 20, 2013 to:

ATTN: Booker Service Award

Center for Animal Human Relationships (CENTAUR)

VA MD Regional College of Veterinary Medicine

225 Duck Pond Drive, Phase II (0442)

Blacksburg, VA 24061

Please contact for any questions or further information. For more information about “The Human Animal Experience: Exploring the Bond” Symposium, please see http://www.cpe.vt.edu/hab/index.html and for CENTAUR, http://www.vetmed.vt.edu/centaur/.