Name: July 16, 2022 Evaluations at Providence Medical Center
Start: 2022-07-16T08:00:00-06:00
End: 2022-07-16T13:00:00-06:00

Name*

Email*

Primary Phone*

Secondary Phone:*

What are you interested in?*

Name of Organization:

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?

Rats
Cats
Mini Horses
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.):

Comment/Message:

Type of Facility:*

Age of Clients (check all that apply):*

Staff Involvement:*

Activity Level of Facility:*

Client Participation:

Name

This field is for validation purposes and should be left unchanged.

July 16, 2022 Evaluations at Providence Medical Center

July 16, 2022 @ 8:00 am - 1:00 pm