Survey - Humane Education Request

1.

Contact Information:

*

Name:

First Required	Last Required

*

Email: Required

*

Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from Wayside Waifs.

Yes, I would like to receive postal mail from Wayside Waifs

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*2.

Question - Required - School or Organization Name:

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - Estimated Number of Students (please note the maximum group sizes vary by program):

*4.

Question - Required - Please indicate the grade level and age of students: *please note that the minimum grade level requirement for all programming is Kindergarten.

*5.

Question - Required - Number of Adult Sponsors:

6.

Question - Not Required - Which program are you interested in?

	Educational Tour
	Kids In Action Project
	PAW-tiquette for Pooches and People: Dog Safety
	Activating Em-PAW-thy
	Virtual Shelter Tour
	Service Projects for Middle or High School Group
	Once U-PAW-n a Time Reading Program
	Large group or Field trip
	Other

7.

Question - Not Required - In response to the question above, if you selected "other", please describe:

(Maximum response 255 chars, approx. 5 rows of text)

*8.

Question - Required - Preferred location of Program:

9.

Question - Not Required - If other, please share full address: * Please note that in order to be good stewards of our resources, locations need to be under 30 minutes and under 20 miles from Wayside Waifs.

(Maximum response 255 chars, approx. 5 rows of text)

*10.

Question - Required - Preferred date of program* Because weekends are our busiest days for adoptions, educational programs are only presented Monday-Friday.

Month

Day

Year

*11.

Question - Required - In case your preferred program date is unavailable, please let us know what day of the week your group is typically available. Please select all that apply:

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

*12.

Question - Required - Preferred start time:

13.

Question - Not Required - Notes:

*14.

Question - Required - How did you hear about our programs?

(Maximum response 255 chars, approx. 5 rows of text)