Jerome Joint School District No. 261

CURRICULUM AND INSTRUCTION 2585F

Student Permission for Exposure to Animals(s)

To be used when therapy dogs are brought into the classroom for educational or therapeutic purposes.

Student: ___________________________________ Grade/Teacher: ____________________________________

Dear Parent(s)/Guardian(s):

As allergies, asthma, immune problems, and/or other health concerns may make animal contact inappropriate for

some students, District guidelines require prior parent/guardian permission for student contact with animal(s) in

school.

For the school year ______________, a therapy dog will visit my classroom for educational or therapeutic purposes:

The building principal or designee will ensure that the District’s policies and procedures for the use of a therapy

dog in education or therapeutic purposes are followed. I will also supervise the entire student-animal contact

session. Under no circumstances are students allowed to clean animals or handle animal waste.

Please complete and return this form to me this date: _______________ . If you have any questions or

concerns, please feel free to contact me at: _______________________________ .

To Be Completed by Parent/Guardian:

_____ I do permit my student identified above to be exposed to the animal listed above. I further agree to indemnify

and hold harmless the School District and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of my student’s exposure to the animal listed above.

_____ I do not permit my student identified above to be exposed to the animal(s) listed above.

Parent/Guardian Name (please print)

___________________________________________________________ _____________________________

Parent/Guardian Signature Date

Parent/Guardian Name (please print)

___________________________________________________________ _____________________________

Parent/Guardian Signature Date

Note: If only one parent/guardian signs this form, please certify the following:

I, ______________________________ (parent/guardian), have full authority to sign and consent to this

Permission Form and Release as an agent of any and all other parent(s) and/or legal guardian(s).

Policy History:

Adopted on: 11/15/2022

Revised on: 00/00/0000