Facility Registration Form
(Please Print and Complete)
Back to Facility Services

Facility Name:_____________________________________________________
Address:________________________________________________________
             _________________________________________________________

Contact Person:____________________________________________________
Phone:_________________________________________________________
E-Mail:_________________________________________________________

Type of Setting:

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:


38 Garden Rd.
Scituate, MA 02066
(781) 264-5537
dogbonestherapydogs@comcast.net