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5056a - Service Animal Request Form

SERVICE ANIMAL REQUEST FORM

___________________________                  ___________________________     

Date                                                                School Building

___________________________                  ___________________________

□ Staff  □ Student  □ Other                             Parent(s)/Guardian(s)

Person assisted by animal

___________________________                  ___________________________

Animal Owner                                                 Handler (if not person with disability)

 

Type of Animal:  □ Dog  □ Miniature Horse     Name of Animal:  ______________

 

If it is not readily apparent that the animal qualifies as a “service animal,” please answer the following questions: 

Is use of the animal required because of a disability? □ Yes  □ No

What work or task has the service animal been trained to perform?

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

I have attached the following documentation:

□  Proof of current licensure

□  Proof of current vaccinations and immunizations from a licensed veterinarian

□  Declaration page indicating adequate liability insurance coverage

 

I have read and understand the school district’s Animals Policy.  I will abide by the terms of that Policy.  I understand that if the service animal is out of control, not housebroken, presents a direct and immediate threat to others in the school, or fundamentally alters the nature of the service, program, or activity that cannot be eliminated by reasonable modifications, the school district may exclude or remove my service animal from its property.

 

I agree to be responsible for any damage to school property or injury to personnel, students, or others caused by the animal.  I agree to indemnify, defend, and hold harmless the school district from and against any and all claims, actions, suits, judgments and demands brought by any party arising on account of, or in connection with, any activity of or damage caused by my service animal.

 

_______________________________                      _______________________________

Owner Signature                                 Date                Parent/Guardian Signature                 Date

 

_______________________________                      _______________________________

Assisted Person’s Signature   Date                            Handler Signature                               Date

 

APPROVAL

 

_____________________________________                      __________________________

School Official Signature                                                        Date

Printed Name:  _________________________                     Title:  _____________________

 

Note: This form is valid until the end of the current school year.  It must be renewed prior to the start of each subsequent school year or whenever a different service animal will be used.

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