Facility Name Facility Phone Number (###) ### #### Facility Website Address http:// Facility Address City/State/Zipcode Are visitors to your facility required to wear a mask? Do you require that visitors to your facility have the Covid 19 vaccination? Contact Name Contact Job Title Contact Email Address Contact Phone Number (###) ### #### Where will visits take place in the facility? (i.e. patient rooms, common room, classroom, counselors office, school library, etc.) Describe your client population.. (i.e. children ages 5-12 who visit public library, students in grade 3 classroom) What day and time do you want this PALS visit? How many pet therapy teams do you need for this PALS visit? (Do you just need one team or multiple teams?) How frequently would you like a visit? (Will this be a recurring, regular visit or a special reading event?) How do you see a pet therapy team benefiting your facility? Please be specific in describing how you want your Pets as Listeners visits to go so that we can find a team(s) that best meets your needs. Do you need any of the records listed below? Check all that apply PTO Certificate Veterinarian Records PTO Insurance PTO Team Photo Is there any additional information you would like to share with us? Thank you! We have received your information and will be contacting you soon. Pets As Listeners Request FormIf you would like to request a PALS visit to your facility, please fill out the form below.
