ADNW Therapy Dog Request Form

General Information

Group/Company Name

Address Line 1

Address Line 2

City

State

Postal Code

Contact Person

Title

Phone Number

Visit Information

Requested Date(s) and Time(s)

Size of Group

Average Age

Please briefly describe your goals for the ADNW Therapy Dog Visit(s) and how much time you would like the dogs to be present:

Are you also looking to have a presentation about Assistance Dogs integrated into the visit as well?

YesNo, not at this time.

If you checked “Yes” to the question above, please check all that apply:

Ability to connect a laptop to a TV or projector.Have a screen or projector.DVD player with TV.