SAMARIA COMFORT DOG
General Visit Request
Interested in scheduling a school visit with Samaria?
Please click here:
School Visit Request
Name
*
First Name
Last Name
Name of Company
Email
*
example@example.com
What is the physical address of the location that the visit will take place at?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name and phone number of alternate contact, if different than listed above:
Date Request: Please note this is only a request and cannot be guaranteed. Once your form is received, Samaria’s Top Dog will contact you with available dates to choose from that best fit your needs. *If you would like a reoccurring visit we will be able to schedule that for you when we connect.
-
Month
-
Day
Year
Date
Start Time Request - Please note this is only a request and cannot be guaranteed.
Hour Minutes
AM
PM
AM/PM Option
End Time Request - Please note this is only a request and cannot be guaranteed.
Hour Minutes
AM
PM
AM/PM Option
Please tell us a little bit about who we will be visiting with:
What type of visit will this be?
Please Select
One-time visit
Recurring Visit
One time with the potential to request recurring visits
Please tell us a little about the location of our visit to the best of your knowledge - The type of business/Church, the size and set up of the room, if the room has chairs/tables/couches. Is the floor carpet or tile. Classroom, day room, private home, etc.:
Will the visit be located indoors?
Please Select
Yes
No - Please give a detailed description below of where you envision the visit to take place.
All outdoor visits are weather permitting and may be canceled if conditions are deemed unsafe for Samaria. Outdoor visits can only proceed if Samaria and her team are kept in a cool, shaded area at all times. If weather conditions are not suitable and an indoor alternative is not available, the visit may need to be rescheduled. (If the location is indoors please skip this question.
If the visit will take place outdoors: Please give a detailed description of where the outdoor area that your visit will take place.
Please give a brief description of the building our team should enter with Samaria. Please share details about where our team should park.
Please give a brief description of the building/door our team should enter with Samaria? Please include directions of where the team should go once inside to meet with our contact:
Is there a special reason for your visit:
Name and phone number of contact the team can meet in person with upon arrival:
How many people do you expect to interact with Samaria during the visit:
Please Select
1-15
16-30
31-50
50-75
75-100
Will you need us to provide any of the following prior to your visit:
Up-to-date vaccination records
Comfort Dog Accreditation
Liability Insurance coverage
Is there a background check process for the team escorting Samaria
Yes
No
Are there any others animals on the property that Samaria will be visiting?
Please Select
Yes, please provide additional details below.
No
If so, please give additional information about any other animals that will be on the property during Samaria's visit.
Is there any other information you can share with us about your visit to help us to give you the best experience possible:
How did you hear about us:
Please be advised that LCC K-9 Comfort Dog Samaria and her team may be called upon to respond to emergencies at any time. In such cases, previously scheduled visits may be canceled with little or no notice.
We appreciate your understanding and flexibility.
The LCC K-9 Comfort Dog Ministry never charges for its services.
Once your form has been received, you will be contacted by Samaria's Top Dog to finalize the details, date, and time of your visit.
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