This form must be completed by a authoritative member of your staff

Your Establishment Details:

Establishment Name:	*
Address Line 1:	*
Address Line 2:	*
Town:	*
County:	*
Postcode:	*
E-mail:	*
Establishment Phone:	*
Establishment Fax:
Your Name:	*
Position of Authority:	*
Total Clients:	*
Average Client Age:	0 - 5 6 - 18 19 - 30 31 - 45 46 - 60 61 - 70 70 + *
Client Abilities:	*
Staff present at all times:	Yes No *
Parking for volunteer:	Yes No *
Establishment Type:	Hospice NHS hospital Private Hospital LA Residential home Private Residential home LA Nursing Home Private Nursing home Special needs School Main stream School Play/holiday clubs EMI Unit Secure Units Day Centre Group home Social Club Adult Mental Health Rehabilitation Unit Other - Please specify Below *
Other Pets Allowed:	Yes No
	*required

Enter any comments in the space provided below:

DATA PROTECTION ACT CONSENT FOR PERSONS REQUESTING
A VISIT FROM A PETS AS THERAPY VOLUNTEER

By clicking Submit I consent to Pets as Therapy (Registered Charity No 1112194: Charity Registered in Scotland SCO38910: a company limited by guarantee) processing my personal data for the purposes of:

• Processing my request for a visit from a registered volunteer

• Sending me information about the work of Pets as Therapy

• Sending me other information which maybe of interest to me