Therapy Dog Visit Request Form
Facility/Requestor Information
Facility Name
Facility Phone Number
Facility Website
Facility Address Line 1
Facility Address Line 2
Facility City
Facility State
Please select...
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Facility ZIP Code
Contact First Name
Contact Last Name
Contact Job Title
Contact Email Address
Contact Phone Number
Questions?
Please contact the Therapy Dog Manager at
landersen@guidedogsofamerica.org
.