APES - Animal Therapy Client Registration

Register to use the Animal Therapy Service. Using this form will allow us to keep information about you and help us to best support and work with you.

Name and Address
Title *
First name *
Last name *
Date of Birth *
Address *
Town *
Postcode *
Email Address *
Confirm email
Home Tel
Today's Date *
Mobile *
	Can we text you on this mobile number?
Who is the therapy for? * Please let us know who this therapy is for, providing information like disabilities or special needs. Please note that we may need to discuss the types of suitable animals before your appointment.
How can we contact you. * This allows us to message you and contact you as and when needed. If you select none, we will not be able to contact you at all.

APES - Animal Therapy Client Registration

Name and Address