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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: |
