Request for Services and Waiver of Liability & Indemnity Agreement
Companion Animal Association Social Pet Therapy Animal Program
 

Name of Facility____________________________________________________________________________________ 

Address____________________________________City______________AZ   Zip code_________________________

Major Cross Streets: ____________________________________Telephone __________________________________ 

Contact Person________________________________________email________________________________________                  Name and title 

The following information will help us better match a pet therapy team to your residents: 

1.        Type of facility and number of residents or participants:

 

2.       Characteristics (e.g., mobile, bed-ridden, dementia, rehab, gero-psych): 

 

3.       Circle times you can accommodate visits:  weekdays      Saturdays      Sundays       evenings (6-7pm)

 

4.        Do you receive other pet visits?             If so, by whom and how often? 

 

5.        Do you have a residential pet?              If so, what species, age? 

 

6.        Any other information about your facility that would be helpful: 

 

 

The undersigned does hereby request the services of the Companion Animal Association of Arizona, Inc (CAAA) Social Pet Therapy Animal Program.

It is understood that CAAA provides this service at no charge and that, in consideration thereof, the undersigned does hereby release CAAA, its volunteers, agents, officers and directors, from any and all liability, actions, or claims for damages arising out of the services to be provided by the CAAA, as requested herein, and the presence of visiting animals at the above location.

The undersigned does hereby warrant and confirm that it shall use its best efforts to ensure that, during the periods of visitation at the above facility, both the welfare of the visiting animals and the persons being visited shall be properly safeguarded.

The Undersigned does hereby further indemnify and hold harmless the Companion Animal Association of Arizona, Inc, its volunteers, agents, officers and directors, from any and all claims whatsoever arising out of or in any way connected with the visitation of animals at the above facility. 

____________________________________________             ______________________________________________
Authorized signature                                                                    printed name
 

__________________________________________                 ______________________________________________
Title                                                                                              date

Return form to         Companion Animal Association of AZ, Inc
                                P.O. Box 5006
                                Scottsdale, AZ 85261-3006                          
                                                                                                                                                                                                                                                                                                                                                              CAAA       Fac.req doc
<Do not write below—internal use only>                                                                                                                                                                                                                                                                                                                          rev jc 2005

Date received:                            Processed by:                                     Team assigned:                              date assigned:

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