 |
Facility
Registration Form
(Please Print and Complete)
Back
to Facility Services
Facility Name:_____________________________________________________
Address:________________________________________________________
_________________________________________________________
Contact Person:____________________________________________________
Phone:_________________________________________________________
E-Mail:_________________________________________________________
Hospital _____
Rehabilitation Center/Hospital _____ Nursing Care Facility _____
Elder Services _____
School _____
Early Intervention Program _____
Other _____
Request for Therapy Dog Team Visits:
Mon. ____ Tues. ____ Wed. ____ Thur.
____ Fri. ____ Sat.____ Sun. ____
AM ____ PM ____ Flexible ____
I would like more information about 
_____
Return this form to: