Animal Assisted Therapy

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CENSHARE Homepage

CENSHARE
University of Minnesota
717 Delaware St SE, Rm 130
Minneapolis, MN 55455-2040

phone (612) 626-1975
fax (612) 624-3370
e-mail: censhare@umn.edu

Webmaster: Patricia Rizzi
rizzi001@umn.edu

Visiting and Working Companion Animal Registration Form

(Name of Facility)

Visiting and Working Companion Animal Registration Form

— Companion animal owner must complete all information—

Companion Animal Owner's Name: ______________________________________

Phone #: (_____) _____ - __________

Address: ____________________________________________________________

City: ___________________________ State: ___________ Zip Code: ___________

Companion Animal's Name: _____________________________________________

Type of companion animal:

Dog: _____ Color: __________ Breed: _____________
Cat: ______ Color: __________ Breed: _____________
Other: ____ Type: ___________ Color: _____________ Breed: ___________

If therapy registered (eg, TDI, TD Inc, Delta Society–Pet Partners, etc), please list registering organization and number:

Check here if you would like information about these therapy organizations.

Yes: _____ No: _____

To all visiting companion animal owners:

Please read and sign the owner statement on the next page. If your companion animal fails to conform to all the standards listed in the statement, it may not visit in the building or anywhere on the grounds of (name of facility). We appreciate your cooperation in playing a part in our visiting and working companion animal program.

Sincerely,

(Name of Facility Staff Member)

(Official Title )

(Name of Facility)

Visiting and Working Companion Animal Program

Owner Statement

As the owner of the previously mentioned companion animal, I make the following statements:

• I have provided a health certificate signed by a licensed veterinarian indicating that my companion dog or cat is up-to-date on all vaccinations and is on a wellness program with a veterinarian. Companion animals other than dogs or cats must have specific approval from the (designated facility staff member).
• My companion animal is house broken, well-groomed, odor free, and not infected with external parasites (ie, ticks, fleas, or lice.)
• I will not bring my companion animal to this facility if it is estrus (heat).
• I understand that my companion animal must be on leash at all times while in the facility or on the grounds and additionally must be controlled by verbal commands.
• I understand that my companion animal should not be in areas where food is being prepared or served.
• I understand that I am liable and responsible for my companion animal's behavior and activities while in this facility.

Owner's signature: _________________________________ Date: ____/____/____

Owner Print Name: ________________________________

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