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OCDSB 912 Request For A Service Animal To Accompany A Student-1- OCDSB 912 (January 2020) Appendix A: OCDSB 912 REQUEST FOR A SERVICE ANIMAL TO ACCOMPANY A STUDENT (References: PR.686.SCO) THIS FORM IS TO BE COMPLETED BY THE PARENTS/GUARDIANS OR ADULT STUDENTS AND SUBMITTED TO THE PRINCIPAL. Name of student: D.O. B.: School: OEN: Name(s) of Parent(s)/Guardian(s): Address: Telephone numbers: Species of Service Animal: Disability-related Needs to be Accommodated by a Service Animal •Please attach a letter from a pediatrician, psychologist, psychiatrist, or other regulated health professional as determined by the District, confirming the student requires the service animal for reasons relating to the disability in order to gain meaningful access to education. Information Regarding the Student •Can the Student Independently manage the animal? Yes No •Describe in detail where, when and how the student currently utilizes the animal’s services in public spaces for accommodation purposes. •Please describe below what, if any, responsibilities the student is capable of performing independently. -2- OCDSB 912 (January 2020) •Please describe below the responsibilities you wish to have assumed by a school staff member. Information Regarding the Service Animal •Please provide a description of the services provided by the service animal to the student, and how those services will accommodate the student’s disability-related needs and assist the student in gaining meaningful access to education. •Identify the oral commands or visual signs to which the animal responds, if applicable. •Please confirm that the animal does not make vocal noises, does not engage in distracting behavior, and does not exhibit aggression. •Identify whether the animal will be on a leash/harness or in a crate. •Describe the biological needs of the animal. -3- OCDSB 912 (January 2020) Information Regarding Service Dogs (Complete only if the service animal requested is a service dog) •Please attach a letter from a registered guide dog/service dog training center stating that a certified service dog has been assigned to the student. •Please attach a copy of the dog’s registration and training certification (not older than 6 months) from an Accredited Training Organization attesting that the dog and the handler have successfully completed training and the dog may safely engage in a public setting without creating a risk to the health and safety of others or of disruption in a school setting. •Please attach a proof of municipal dog license/registration (to be updated annually). •Please attach a copy of training certification of the Handler (individual responsible for the dog). Veterinary Certificate •Please attach a certificate from a veterinarian qualified to practice veterinary medicine in the Province of Ontario (Confirmation to be updated annually) attesting to: ○The species of the service animal, age and confirmation that the animal is an adult ○The service animal does not have a disease or illness that might pose a risk to humans or dogs ○The service animal has received all required vaccinations; and ○The service animal is in good health to assist the student. Insurance •Documentation of insurance (minimum of $1M) as it relates to the service animal and assumption of all liability related to the service animal’s behavior (to be updated annually). I/We acknowledge that we are responsible for costs for the service animal, including, but not limited to, training, veterinary care, and other related costs. Signature(s) of Parent(s)/Guardian(s)/Adult Student: Print name(s): Date: The personal information on this form is collected under the authority of the Education Act (RSO.1990 c.E.2) ss. 58.5, 265 and 266 as amended, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (RSO.1990 c.M56), as amended. It will be used for student and education related purposes, such as administration, communication, and data reporting. In addition, the information may be used or disclosed to comply with legislation, for compelling circumstances affecting the health and safety or discipline, as required in circumstances related to law enforcement matters, and with third parties in accordance with established service agreements or in accordance with any other Act. Questions or concerns should be directed to the school principal or the District's Freedom of Information Coordinator, Ottawa- Carleton District School Board, 133 Greenbank Road, Ottawa, Ontario K2H 6L3, Telephone 613-596-8211, ext. 8607.