-
SERVICE ANIMAL REQUEST FORM
Date:
School Building (circle one): Barrie Luther Purdy Rockwell MS HS
Type of animal: _____ Dog _____ Other
Name of animal:
Is use of the animal required because of a disability? ____ Yes _____ No
What work or task has the service animal been trained to perform?
Person assisted by animal:
Name of parent(s)/legal guardian(s) (if person assisted is a minor):
Address:
Phone number: Email:
Animal Owner (if different from parent/legal guardian):
Address:
Phone number: Email:
Handler (if different that person assisted by animal):
Address:
Phone number: Email:
SERVICE ANIMAL REQUEST FORM
Is the service dog in compliance with all state and local requirements associated with licensing, vaccinations and other health regulations? _____ Yes _____ No
Please attach the following documentation:
? Proof of current licensure for service animal
? Proof of current vaccinations and immunizations from a licensed veterinarian
? Proof of current certification for the handler
? Proof of adequate insurance coverage
For office use only: (initial and date)
License : ____________ Date: ___________
Vaccinations/immunizations: _____________ Date: __________
Handler certification: ____________ Date: ___________
Insurance coverage: ______________ Date: __________
I have read and understand the School District of Fort Atkinson’s Service Animal 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 animals from its property.
I agree to be responsible for any damage the 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 connections with, any activity or damage caused by my service animal.
Parent/Guardian Signature: Date:
________________________________________________________________________________
Owner Signature (if different from parent/legal guardian) : Date:
________________________________________________________________________________
Handler Signature (if not person with disability): Date:
________________________________________________________________________________
