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January 17 @ 7:00 pm
Location – tbd
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7:00 pm - 9:00 pm
Name of Organization:
What are you interested in?
Organization Seeking Teams
Becoming a Therapy Team
Are you interested in:
A Special Event (a single event or an event occurring once or twice per year)
A Therapy Animal Visiting Program (a visiting program that occurs on a regular schedule(weekly, monthly, quarterly)
Name of Your Event:
Description of Your Event:
Day(s) of the Week, Date, and Beginning/End Time of Your Event:
What species would you like to have participate in your event?
Dogs (they will need a grassy area to relieve themselves- handlers will dispose of waste.)
Approximately how many people will be attending your event?
Total number of teams you would like for your event:
Address and name of building for your event:
What is the approximate size of the space where the animal teams will be visiting with the clients/patients/residents?
Day of contact person and phone number:
Parking Information (will parking be provided, where should teams park, will they need parking passes, etc.):
Type of Facility:
Healthcare (eg; hospital, rehab/skilled nursing, hospice)
Education (eg; school, library)
Residential (eg; group home, senior living)
Age of Clients (check all that apply):
High (eg; accompany, supervise)
Low (eg; provide a visit list)
Activity Level of Facility:
Active (eg; many distractions, routinely unanticipated interactions, potentially volatile)
Moderate (eg; some distractions, occasional unanticipated interaction)
Quiet (eg; routine interactions, predictable setting)
Client Participation (check all that apply):
Individual (eg; one on one)
Small group (eg; less than 5)
Medium group (eg; 5-15)
Large group (eg; more than 15)
Questions or Comments?
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