AR383.1 (Exhibit) - Service Animals in Schools





    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):



    Phone number:                                                                                              Email:




    Animal Owner (if different from parent/legal guardian):         



    Phone number:                                                                                              Email:                                                                                                                                     



    Handler (if different that person assisted by animal):



    Phone number:                                                                                              Email:







    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:



Related Files