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Request to be Accompanied by a Service Animal: JLIF-2

  • Students: J
Request to be Accompanied by a Service Animal: JLIF-2
Updated

Students should submit this request to their building administrator. Employees should submit this request to the Human Resources office. Completed request forms should be kept in the student’s cumulative folder or in the employee’s personnel folder, whichever is applicable.

Date: ___________________

Student Name: _______________________ Employee Name: ____________________

Owner/Handler: ______________________ Location: __________________________

Is the Service Animal required by a disability: [ ] YES [ ] NO

What work or tasks has the service animal been trained to perform? Please describe below: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Type of Animal: [ ] Dog [ ] Miniature Horse Name of Animal: ______________________

----------------------------------------OFFICE USE ONLY BELOW-------------------------------------

School Nurse Review: School nurse has reviewed health needs of all students enrolled in building and determined [ ] no known health risk to others [ ] known health risk to others

If there is a known health risk to others, an accommodation plan [ ] has [ ] has not been created If an accommodation plan has been created, please attach to this form.

Use of Service Animal is APPROVED [ ]

Use of Service Animal is NOT APPROVED [ ] (explain) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Signature of Building Administrator: _________________________________ Date: ________

Signature of School Nurse: __________________________________________ Date: _______