Name: 12/6/25 – Team Evaluations at Providence Medical Center
Start: 2025-12-06T08:00:00-06:00
End: 2025-12-06T13:00:00-06:00
Location: Providence Medical Center

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:

Individual (eg; one on one)
Small group (eg; less than 5)
Medium group (eg; 5-15)
Large group (eg; more than 15)

Email

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

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