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Puppy Therapy Event Intake Form
After completing the form, someone from our team will be in touch with you within 48 hours to discuss your request. Thanks for your interest in our puppy therapy program!
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* Indicates required question
Email
*
Your email
First and Last Name:
*
Your answer
Event Location Address:
*
Your answer
Contact Number:
Your answer
Contact Email:
*
Your answer
Name of Facility:
*
Your answer
Event type:
*
Healthcare (hospital, nursing home, retirement/senior home)
Education (school, college, library)
Family/Community Services (Church, birthday party, wedding)
Other (mental health awareness event, conference, business meeting etc.)
Month/Date of Visiting Request
*
Choose
As soon as you're available
Within the next 3-6 months
Specific time
If specific time, please confirm date:
Your answer
Age of person's receiving visits:
*
Children
Adults
Seniors
Required
Number of person's receiving visit:
*
Individual
Small group (less then 5)
Medium group (5-15)
Large group (more than 15)
Required
If more then 50 attendees, please give an approximate number:
Your answer
How often would you like this event to take place?
*
One-time
Recurring monthly
Recurring semi-monthly
Twice a year
Once a year
Undecided
Required
A copy of your responses will be emailed to the address you provided.
Submit
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