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Code No. 105 R1

Name of administrator: ________________________    

Signature of administrator: ________________________

Name of animal owner: ______________________________

Signature of animal owner: ______________________________

Student being served: ___________________________

Name of animal: __________________________

Type of animal: _________________________

Date of review decision: __________________ 

Yes

No

Is the animal trained to provide a disability-related service for a student or adult with a physical or mental impairment that significantly limits one or more major life activities?

Has the function of the service animal been demonstrated?

The animal has demonstrated the ability to perform the service.

Is the service animal required for the student/adult to access the services of the school?

Is the animal within the type, size, and weight limits prescribed by law?

Can the school facility accommodate the animal without compromising safety?

Has the owner provided proof of vaccinations? Date when vaccinations need to be renewed ______________________

Owner initials

Admin initials

I understand, that due to others’ fears, the animal may be required to sit outside the classroom, within the line of sight of the student/adult.

I understand that I am responsible for providing for the animal’s physical needs. This includes food, water, and waste elimination.

I understand that neither the animal nor the handler may be a distraction or detriment to the normal learning environment.**

I understand that the animal must be under positive control at all times. 

I understand that failure to provide any of the above will be grounds for excluding the service animal.

I understand that therapy and emotional support animals may be admitted on a case-by-case basis after review of the district superintendent.

Record of Concerns:

*Attached printed copies of communication to the back of this document, including notifications of exclusion where applicable.

Date

Nature of the concern

Communication method

** The following list describes some, but is not limited to, distractions that will be considered a detriment to the normal learning environment.

·       Biting – regardless of how hard or if the biting motion actually makes contact with a human

·       Barking

·       Eliminating waste indoors

·       Foul odors

·       Muddy paws or coat

·       Infestation such as fleas or ticks

·       Incessant scratching

·       Confrontation with other animals

·       wandering

·       other