Garfield Re-2 Policies

JLIK-E-23-24 Initial Therapy Dog Request Form

JLIK-E

23-24 Initial Therapy Dog Request Form

A therapy dog provides therapeutic support to people other than its handler. Therapy dogs do not have federally granted legal access to the types of public areas afforded to service dogs. In order to receive permission to bring a therapy dog to your school, please fill out the following form. Applications are accepted for the Fall Semester through September 30, 2023, and for the Spring Semester through January 1, 2024.

After this initial application, a RENEWAL APPLICATION HAS TO BE SUBMITTED WITH PROPER PAPERWORK EVERY NEW SCHOOL YEAR

PLEASE SCAN IN ALL REQUIRED DOCUMENTS BEFORE FILLING OUT THE FORM.

Proof of Liability Insurance
Therapy Dog Certification
Handler Registration and / or Handler ID
Vaccination Record
A copy of the current Dog Health Screening from a local veterinarian -please use this form

APPENDIX: INFORMATION FOR HANDLERS / OWNERS REQUESTING A THERAPY DOG AT SCHOOL

I. The success of the implementation of a therapy dog program that is tied into the curriculum depends on clear communication, a well-informed school community and careful planning. The information you provide will assist the school principal and ADA Manager to make the best possible decision. The information will be filed in your in your record at the school.

I understand that I am required to participate in meetings requested of me by the school principal.

I understand that for the safety and protection of students and staff, which is necessary for the safe operation of the school, the school may revoke access because:

The therapy dog is not under control at all times
The therapy dog is not housebroken
The therapy dog is not on a leash or tether at all times
The therapy dog poses a direct threat to the health of any student, staff member or any other person at school
The therapy dog presence otherwise interferes with the educational program
A staff member or student shows anxiety while the therapy dog is present
The handler brought the therapy dog to school prior to submitting and authorizing appropriate paperwork to the ADA Manager
The handler fails to follow the permission procedure and the school principal's instructions

I understand that I am the therapy dog handler and I am solely liable for any damage to persons, premises, or facilities that was caused by the therapy dog. I will hold the district, its employees, or agents harmless for any injury.

The information you provide will help the school principal and the appropriate staff implement your request. It is important to provide the information that addresses the safety of the students and staff. For example, the school principal needs to know that the dog has no history of nipping, biting, or growling at children or adults, nor exhibits aggressive protective behaviors.

The well-being of the dog is of utmost importance. Its care, handling, and training need to be addressed, and your input as the handler is valuable. The school principal also needs to know what other resources are available to facilitate the transition to school and the implementation of the plan. Strategies for becoming familiar with the building and school grounds, and an introduction to staff rooms (if applicable) must be included in the planning to be as consistent and fair to the dog as possible. NOTE: A school is not a training facility for therapy dogs that have not finished their training. The training itself needs to happen outside of school. The handler needs to be in full control before a transition training with the dog can be considered and integrated into the plan.

The school principal, with assistance, will develop a communication plan that informs students, staff, and community members as appropriate.

Once the necessary information has been received, the school principal will consult with the ADA Manager prior to admittance and implementation of the therapy dog program. The ultimate decision of offering a Therapy Dog Program will lie with the school principal.

FORM

The name and photo associated with your Google account will be recorded when you upload files and submit this form. Only the email you enter is part of your response.

Any files that are uploaded will be shared outside of the organization they belong to.

* Indicates required question

Email*

Date*

<today’s date>

Handler’s /Owner’s Name*

Handler’s /Owner’s Phone Number*

I am*

Employee
Volunteer
SRO
Other
If Other, what is your role? <your answer>

Position within Garfield Re-2 (if applicable)

Is this the first year the dog is at school? If not, how many years has it been there? *

What is the dog’s Name and Breed? *

School / Site where the therapy dog will be used? (Choose all that apply) *

Kathryn Senior
Elk Creek
Riverside
Cactus Valley
Wamsley
Highland
Graham Mesa
Rifle Middle School
Coal Ridge
Rifle High School

How long will the therapy dog be at the location? (days/hrs.) *

When will the therapy dog be there? (Select days) *

Monday
Tuesday
Wednesday
Thursday
Friday

Is the visit recurrent? *

Does the therapy dog meet all minimum standards? (It is clean, well-groomed and does not * have an offensive odor – Does not urinate or defecate in inappropriate locations – Does not solicit attention, visit or annoy any member of the general public – Does not vocalize unnecessarily, i.e., barking, growling or whining – It shows no aggression towards people or other dogs – Does not solicit or steal food or other items from the general public)

Will the therapy dog be tied to the school's curriculum? *

Please describe in detail what the therapy dog will do at school? *

I, the Handler/Owner, acknowledge that I have read and agree to the terms. (Your typed name represents a digital signature. *

A communication plan that informs students, staff, and community members, as appropriate, regarding the use of a therapy dog has been developed and communicated. Please share the date of communication below:

Date <selectable date field>

Attachment - Proof of Liability Insurance*

Attachment - Therapy Dog Certification*

Attachment - Handler Certification or Handler ID*

Attachment - Copy of current Garfield Re-2 Therapy Dog Vet Screening Form from a local Veterinarian - <Add file>

File: JLIK-E

< Garfield Re-2 Therapy Dog Vet Screening form>

Garfield Re-2 Therapy Dog Vet Screening Form

**Please make a copy before completing**

Handler Name:

Handler Phone:

Handler Email:

Dog’s Name:

Vet Name:

Vet Facility (Name/Address):

Vet Phone:

Vet Email:

Date of Vet Exam:

Date of Negative Fecal Exam:

Date of Rabies Vaccination:

One Year

Three Year

Current Immunization Record is attached

**The dog listed on this form has been examined in this clinic and is believed to be healthy, up to date on vaccinations, and free of internal and external parasites as of the exam date listed above.

Vet Signature/Clinic Stamp:

Printed Name:

Date Signed:

Adopted: October 11, 2023

Garfield School District No. Re-2

J - Students