University of Wisconsin-Stevens Point
Assistance Animal Agreement for UWSP Student
I have read and understand the UWSP Assistance Animal section of the policy and procedures. 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 an assistance 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 assistance animal accommodations.
And I give permission for the information on this page to be provided to appropriate stakeholders
needing to be aware of the assistance animal’s presence; including the director/coordinator of
Residential Living, Protective Services and Dean of Students.
Assistance Animal
______________________________________________________________
Dog tag license
Rabies tags
( ) Yes ( ) No Tag number _______________________________________
( ) Yes ( ) No Tag number _______________________________________
Animal name
______________________________________________________________
Contact person to assume custody of the assistance 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
Protective Services
Residential Living