Administrative Guidelines

Appendix A

Appendix A

Niagara Catholic District School Board

Student Use of Service Animals in Schools Request Form

This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and under the Authority of the Education Act, and will be used by Special Education to determine eligibility for the use of Service Animals in schools. Questions about this collection should be directed to the Superintendent of Education – Special Education, Niagara Catholic District School Board,427 Rice Road, Welland, Ontario L3C 7C1, 905-735-0240.

Student Name

[ ] M [ ] F

Date of Request

mm/dd/yyyy

Parent/Guardian		Contact Number
Address		Work Number
City/Postal Code		Date of Birth mm/dd/yyyy
School		Teacher
Grade Level		OEN #

[ ] Guide Dog [ ] Certified Service Animal Other [ ] please specify ________________________________

REASON(S) FOR REQUEST

________________________________________________________________________________________________

________________________________________________________________________________________________

STUDENT

1. Will the student act as the primary Handler and independently manage the service animal? Yes No

2. Describe in detail where, when and how the student currently utilizes the services of the service animal in public

spaces for accommodation.

______________________________________________________________________________________

SERVICE ANIMAL

1. Describe in detail the tasks or services performed by the service animal.

________________________________________________________________________________________________

2. Identify the oral commands or visual signs to which the service animal responds.

________________________________________________________________________________________________

3. Identify whether the service animal will be on leash/harness or in a crate.

________________________________________________________________________________________________

4. Describe nutrition breaks and biological needs of the service animal.

________________________________________________________________________________________________

REQUIRED DOCUMENTATION

The following documentation has been provided to support this request:

an assessment report from a registered pediatrician, psychologist, or psychiatrist containing the diagnosis and description of the disability-related learning needs or acts of daily living to be accommodated, and the services the Guide Dog / Service Dog will provide to support the student achieving their learning and daily living goals in a school setting;

a certificate (no older than 3 months) from a veterinarian qualified to practice veterinary medicine in the Province of Ontario attesting that, the dog is an adult; identifying the age and breed; does not have a disease or illness that may pose a risk to humans; has received all required vaccinations; and is in good health to assist the student (required annually);

confirmation of certificates of training (no older than 6 months) from an Accredited Training Organization attesting that the dog and student Handler have successfully completed training and may safely engage in a public setting without creating a risk of safety or a risk of disruption within a school setting.

a copy of the Municipal Dog License (required annually)

Insurance Certificate providing coverage in an amount specified by the Board in the event of an injury or death as a result of the presence of a service animal on school property or on a school-related activity (required annually)

RESPONSIBILITIES

I/We understand that it is our responsibility to:

adhere to all aspects of the Niagara Catholic Student Use of Service Animals in Schools Administrative Operational Procedures (303.2) and work collaboratively with the principal, school and Board staff;

be financially responsible for any costs incurred for the care of the service animal including but not limited to: veterinary care, food, grooming, harness, crate and/or mat;

ensure that the Service Animal is groomed, clean, and in good health prior to entering the school building or school-related activities; and

arrange for the personal care and physical needs of the service animal, including bio-breaks and the removal and disposal of waste in a safe and environmentally friendly manner.

promptly pick-up the service animal from the school, if requested.

UPON APPROVAL

I/We give permission for the school to provide information in writing to the school community;

daycare providers using school facilities; and the parents of the students in any of the classes where the

service animal will be present to support a student while attending school or a school related event respecting the student’s right to privacy regarding their disability and specific learning needs and/or needs of daily living.

I/We understand that the principal shall preserve the confidentiality of all information received from me/us, and shall not disclose the information except as provided for in the Municipal Freedom of Information and Protection of Privacy Act, the Education Act or as otherwise required by law.

I/We consent to the use and disclosure of the information by the principal to such other Board personnel as may be required for the performance of their duties.

Name of Parent/Guardian: __________________________________________________________________

Please print

Signature of Parent/Guardian: _________________________________ Date: ________________________

For Office Use Only:

Request for Student Use of a Service Animal in Schools: Approved _____ Denied ______

Signature of Principal: _______________________________________ Date: ______________________

Signature of Family of Schools’ Superintendent: _______________________ Date: ______________________

Note usually 2 million in general liability insurance coverage is requested. This requirement might need to be waived on the basis of equity in the event that it causes financial hardship for a family.