SERVICE ANIMAL ACCESS FORM REQUEST
5. Name of person needing the service
animal
6. Status of person needing the service
animal
Check one
Student Visitor Employee Other
7. School or work location where
service animal is needed
8. Is the service animal required
because of a disability?
9. How often will access be needed?
One time access to single event/activity.
Short-term repeated visits to one school/work area between
____________________and
Long-term access to one school/work area. Give name of
school/work area
Long-term access to multiple schools/work areas.
Access to transportation (school bus).
10. What work or task(s) is the service
animal trained to provide?
11. Do you have documentation that the
service animal is licensed by Palm
Beach County
YES NO
If yes, attach the documentation.
If No, access will not be granted.
12. Who is the handler (the person who
will provide direct supervision and
control of the service animal)?
Print Handler’s Name
Handler’s Signature
Date Phone Email
Your signature below confirms that you have read and understand the
service animal policy and agree to the following:
a. The School District is not responsible for the care and/or
supervision of the service animal.
b. The owner is responsible for any damage or injury caused by
the service animal.
c. To implement the plan that will have to be crafted to meet the
needs of the service animal.
d. If the handler is someone other than a student or employee, a
background check will be required at the handler’s expense.
Your Signature Date
click to sign
signature
click to edit
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click to sign
signature
click to edit
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