Request a Therapy Dog Session
The information you provide on this form is considered confidential by Vancouver ecoVillage and will only be used to manage the application, selection and coordination of applicants requesting a therapy dog session or event. Your personal information will not be disclosed to a third party without your consent, unless required or authorized to do so by law or other regulation. This form is kept on file by our office for all active requests.
Website:
www.vanecovillage.com/therapy-dog-program
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Legal Name
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Your answer
Name of Organization, Department, Association (be specific)
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Your answer
Date of Birth (day-month-year)
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Your answer
Address
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Your answer
Phone Numbers (Mobile + Home)
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Your answer
Email
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Your answer
Co-Manager/Other Event Coordinator (Name, Email, Phone number):
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Your answer
Describe the kind of therapy dog session or event you are requesting.
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Your answer
How many sessions are you requesting?
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Your answer
What are your preferred dates?
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Your answer
What is your preferred time? How long will the session last?
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Your answer
Where is the exact address for the session?
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Your answer
Total number of people (adults/children) who will attend the session/event?
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Your answer
What amount can you contribute as a donation to the therapy dog program? (Your donation will cover costs such as insurance and transportation fees for the handlers + therapy dogs to attend your venue.) Provide an estimate even if not exact.
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Your answer
Is your contribution a one time donation or recurring to cover all the costs of each date requested? Please explain.
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Your answer
Photo Release
I UNDERSTAND THAT VANCOUVER ECOVILLAGE (VE) IS DOCUMENTING ON FILM AND PHOTO THE PROGRESS AND EVOLUTION OF ITS EVENTS AND RELATIONSHIPS. I UNDERSTAND THAT VE MAY INCLUDE PHOTOS OR FOOTAGE IN THEIR DOCUMENTARY MATERIAL OF ALL THOSE WHO WILL BE PARTICIPATING IN THE SESSIONS/EVENTS/ACTIVITIES I AM REQUESTING. I AGREE THAT PHOTOS OR VIDEOS OF THEM MAY BE USED FOR MEDIA PURPOSES.
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Yes
No
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Release of Liability, Waiver of Claims, Express Assumption of Risk and Indemnity.
I understand that this agreement absolves Vancouver ecoVillage from any liability, financial or otherwise, which may result from any personal injury to all those who will be participating in the session/event/activity I am requesting, whether caused by dogs and handlers, members, volunteers, staff, guests or others.
Vancouver ecoVillage Society activities and events include but are not limited to activities organized through our website
www.vanecovillage.com
or via members. These events/activities include but are not limited to indoor and outdoor activities. This agreement refers to all participants of visits and events, whether adults or children and their guardians. All participants hereby affirm, acknowledge and agree to the following:
Participants understand that during their participation in any events/activities, they may be exposed to a variety of hazards and risks, foreseen or unforeseen, which are inherent in each event/activity and cannot be eliminated without destroying the unique character of the event/activity. These inherent risks include, but are not limited to, property loss or damage, getting personally lost, trapped or separated from the group, and the dangers of serious personal injury and death (“Injuries and Damages”) from exposure to the hazards of our activities. Participants know that injuries and damages can occur by natural causes, equipment failure or activities of other persons, animals, insects, plants, our surroundings, members, dogs and handlers, volunteers, staff or third parties, either as a result of negligence or because of other reasons. Participants understand that risks of such Injuries and Damages are involved in indoor and outdoor activity such as the Vancouver ecoVillage activities/events and appreciate that they may have to exercise extra care for their own person and for others around them in the face of such hazards. They further understand that on any event/activity there may not be rescue or medical facilities or expertise necessary to deal with the injuries and damages to which they may be exposed.
Therefore in consideration for participating in events/activities, to the fullest extent allowed by law, participants agree to WAIVE, DISCHARGE CLAIMS, AND RELEASE FROM LIABILITY the organizers, dogs and handlers, volunteers, staff or other members of Vancouver ecoVillage Society from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence, in any way connected with our events/activities. Participants further agree to HOLD HARMLESS the dogs and handlers, organizers, staff, leaders, volunteers or other members of Vancouver ecoVillage from any claims, damages, injuries or losses caused by their own negligence while a participant on the visits/events. Participants understand and intend that this assumption of risk and release is binding upon their heirs, executors, administrators and assigns, and includes any minors or pets accompanying them on the events/activities. All Participants have read this document in its entirety and freely and voluntarily assume all risks of such Injuries and damages and notwithstanding such risks, agree to participate in the events/activities they attend under these terms.
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I have read completely and FULLY UNDERSTAND and AGREE to the above.
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