Print Form University of Wisconsin-Stevens Point Service Animal Agreement for UWSP Student I have read and understand the UWSP Service Animal Policy and Procedure. I realize that I am fully responsible to comply with the provisions of this policy. I understand that if there is a violation by others regarding my rights as an individual with a disability accommodated by a service animal (as identified in the policy), that corrective actions will be determined and taken by the appropriate campus department. If I violate any of the provisions, I realize that I may be subject to sanctions identified in the policy, as well as liable for cost of damages and/or injury to others, and my possible loss of the service animal accommodations. And I give permission for the information on this page to be provided to appropriate stakeholders needing to be aware of the service animal’s presence; including the directors/coordinators of Facility Services, University Dining Services, Residential Living, Protective Services and Dean of Students. Dog tag license Rabies tags ( ) Yes ( ) No Tag number _______________________________________ ( ) Yes ( ) No Tag number _______________________________________ Animal name ______________________________________________________________ Contact person to assume custody of the service animal in the event of an emergency: _________________________________________ Name ____________________________________ Phone number I agree to the above: _________________________________________ Student or Employee Name (type or print) ____________________________________ UWSP ID Number _________________________________________ Student or Employee Signature ____________________________________ Date Signed _________________________________________ Director Name ____________________________________ Department (DATC or EAA) _________________________________________ Director’s Signature ____________________________________ Date Signed Cc: Dean of Students Dining Services Protective Services Residential Living