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Appendix A <br />OCDSB 912 School Operations (November 2017) <br />OCDSB 912: REQUEST FOR A SERVICE DOG TO ACCOMPANY A STUDENT <br />(References: PR.686.SCO) <br />THIS FORM IS TO BE COMPLETED BY THE PARENT(S)/GUARDIAN(S) OR <br />STUDENT OF 18 YEARS OF AGE AND OVER AND SUBMITTED TO THE <br />PRINCIPAL. <br />Name of student: D.O. B. <br />School: OEN: <br />Name(s) of Parent(s)/Guardian(s): <br />Address: <br />Telephone numbers: <br />a) I/We request that ________________________ be authorized to have a Service Dog <br />attend at school and at school-related activities. <br />b)The Service Dog will provide the student with the following assistance (attach <br />documentation as necessary): <br />c)Length of time the student and dog have worked together: <br />d)Duration of the requested intervention: <br />e) Documentation submitted with this request: <br />1.a letter from a physician, or another health professional as identified in Ontario <br />Regulation 191/11 Integrated Accessibility Standards, confirming the student <br />requires the dog for reasons relating to the disability; <br />2.a copy of dog’s registration and training certification with a recognized training <br />centre; <br />3.a copy of current, official vaccination certificate for the dog; <br />4.proof of municipal dog licence; <br />5.a copy of training certification of the Handler (individual responsible for the dog), <br />if applicable; <br />6.a copy of liability insurance coverage. <br />I/We acknowledge that we are responsible for costs for the dog, including, but not <br />limited to, training, veterinary care, and other related costs. <br />Page 1