Assistance Dogs
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WORKSHOP REQUEST

Potential Sponsor/Organization, Please Fill Out the Following.
Preference for Workshop Date(s):
Organization Name:
Contact Person:
Address:
Phone:
Fax:
Email:
Good times to reach you:

Type of Organization (Select one or more):
Private practice facility
Local or National Therapy Association
University Program (Specify program department)
Community Based Human Services
Pet Therapy/Animal Assisted Therapy Club or Organization
Assistance Dog Training Organization

We would like to talk further with you about (Please select all that apply)
One Day Introduction to Theraputic Agents and Assistance Dogs (Morning session is on Theraputic Agents and Afternoon is on Assistance Dogs)
One Day Workshop: Theraputic Agents
One Day Workshop: Assistance Dogs as an Assistive Technology Option
Two Day Workshop: Combination of Option 2 and Option 3. Full Day Therapeutic Agents & Full Day Assistance Dogs as Assistive Technology Options
Customized Topic/Specialty Combinations. Specify topics of interest:

Expected attendees (Select all that apply)
Teachers Counselors
Educational Assistants Behavior Therapists
Parents Recreational Therapists
Speech and Language Pathologists Assistance Dog Trainers
Occupational Therapists Social Workers
Phycical Therapists Community Members
Other:

Estimated number of participants
What would the hours of the training be?
What airport would our speaker and dog fly into?
Over night accommodations will be at:
(name and address of the hotel)
How long will it take to drive to the airport after the training?
Can you provide the following?
Audiovisual Equipment
yes no 		A room with chevron or "U" setup
yes no
Area for registration sales and reference tables
yes no 		The use of dogs, wheelchairs and walkers, etc. for activities upon lecture content and needs
yes no
Please let us know anything else that will help us to provide the type of training that would be useful to you. Be as specific as possible:




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