Education — Horticultural Therapy Services

Name of Agency:

Contact Person:

Street Address:

E-Mail Address:

(We must have this to respond to you by e-mail)

Phone:

Fax:

Please describe the audience(s) served by your agency:

What are your goals for the program,
i.e., socialization, recreation, etc.?

If in Cook county, please indicate district number
and county commissioner's name: