LCC K9 Samaria visit request

If your visit will not take place at a school, please click here:

General Visit Request

Name*

First NameLast Name

Name of School *

Email*

example@example.com

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Name and phone number of alternate contact, if different than listed above:

Is this a one time or recurring visit?*

Date Request for a One-Time Visit: 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 please use the next space below.

Date

Starting Date Request: Please note this is only a request and cannot be guaranteed. We will follow up directly to select dates that work best for your calendar and Samaria’s schedule.(This will be a repeating monthly visit beginning on the requested date unless other arrangements are made.)*

Date

End date for school year: *

Date

Requested start time: Samaria and her team will arrive about 5 minutes early so that they can be in place and ready for the start time with students. The visit will be up to 45 minutes long. If you prefer a shorter time please let us know. *

Hour Minutes

AM/PM Option

Requested end time: Samaria's visit can be up to 45 minutes long. If you prefer a shorter time please let us know, otherwise the visit time will default to 45 minutes automatically. *

Hour Minutes

AM/PM Option

Please tell us a little bit about who we will be visiting with and the grade levels of the students for our visit.*

Please tell us a little about the location of our visit, to the best of your knowledge. A calm and quiet environment with adequate space helps ensure Samaria and her visitors are comfortable and supports meaningful connection.*

Please give a brief description of the building our team should enter with Samaria.Please share details about where our team should park.*

.

Please include directions for where the team should go once inside the building and who they should make contact with (example: check in at the front office and wait for an escort to the classroom). *

Name and phone number of the contact the team should meet with in person upon arrival:*

Will a background check be required for the team to visit?*

Up-to-date vaccine recordsComfort Dog AccreditationLiability Insurance Coverage

Is there a special reason for your visit? Please give a bit of information about your goal for Samaria’s visit (example: students will read to Samaria or Samaria will provide emotional support for students).

How many people total do you expect to interact with Samaria during the visit? (Samaria visits with 3–4 people at a time. Classes will need an adult to help rotate students during the visit.)*

You understand that a staff member must be present with Samaria and her team for the entire visit. If a staff member is not available, the visit will need to be rescheduled. *

Is there any other information you can share with us about your visit:

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.

School Visit Request