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AUTHORIZATION and RELEASE for “Approved Dog” Status GENERAL INFORMATION Employee Name: Date: Department: Phone: Sup...

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AUTHORIZATION and RELEASE for “Approved Dog” Status

GENERAL INFORMATION Employee Name:

Date:

Department:

Phone:

Supervisor: Number of Days (per month) dog will be present in the work place:

DOG DESCRIPTION Breed:

Weight:

Age:

MEDICAL INFORMATION: The employee/owner of the dog agrees to maintain copies of all pertinent and current pet medical information on premises with Human Resources:  Certificate of Veterinary Inspection/health certificate  All vaccinations, including bordetellosis and rabies, are complete and current.  Parasite control is being done on a routine basis and the animal is free of ticks and fleas.  The dog has no recent history (6 months) of infection or ringworm. CERTIFICATION/TRAINING: 

The employee/owner of the dog must provide proof of passing the AKC Canine Good Citizen (CGC) test or equivalent to Human Resources.

CERTIFICATION/TRAINING: 

The employee/owner of the dog must provide proof of canine liability insurance with a minimum of $50,000 coverage which can be purchased through your renters or homeowners insurance.

GUIDELINES: The employee/owner of the dog agrees to observe the following guidelines. Authorization is granted at the sole discretion of The Arc of the Capital Area and can be revoked at any time.  The employee/owner will ensure the dog is fully house trained/broken in various environments. The employee is solely responsible for all immediate/appropriate disposal of dog waste and clean-up inside and outside the building, including disinfectant measures.  The employee/owner must have verbal or loose leash control the dog at all times.  The employee/owner has sole responsibility for care of the dog while on the premises and will be responsible for maintaining work productivity levels.  The dog must be secured on leads at all times on business premises outside of buildings.  Water, comforts, and food must be provided for the dog by the employee/owner.

      

All dogs must be treated humanely. A high standard of animal compassion is expected of all pet owner employees. Toys that produce loud sounds or squeaking are prohibited. Employee/owner will be held fully responsible for any damage that is done to the property or its employees. Any display of aggressive behavior or becoming ill will require immediate removal from the premises. Any employee asked to take their dog home must do so immediately. Employees will be responsible for making up any resulting lost productivity. Dogs must not be allowed to wander unattended, inside or outside the building. Dogs may only attend meetings if they are quiet and do not distract participants or owners. Employee/owner will provide a safe and comfortable place for their dogs within their workspace.

WAIVER OF LIABILITY: In consideration of being permitted to bring one’s dog to the work place, the dog owner hereby unconditionally releases, indemnifies, waives, discharges and agrees to hold harmless The Arc of the Capital Area staff, students, guests or visitors from any loss, damage, liability and expense, including court costs and attorney fees, that may be incurred as a result of injuries, including death to persons or dogs, or damage to property, directly or indirectly associated with the owner bringing his/her dog to the work place, whether caused by the negligence of other staff, faculty, students or guests, or otherwise. BY SIGNING THIS AUTHORIZATION AND RELEASE, THE DOG OWNER EXPRESSLY ACKNOWLEDGES AND REPRESENTS that he/she has carefully read the foregoing terms and conditions, understands the contents thereof and signs voluntarily; he/she is at least eighteen (18) years of age and fully competent; and executes this Authorization and Release intending that he/she, his/her spouse and family members, and his/her heirs, assigns and personal representatives if deceased, be legally bound by same. _____________________________________________________ NAME

__________________ DATE

EXECUTIVE APPROVAL: I have discussed the foregoing Authorization and Release with the dog owner and am agreeable to the employee bringing his or her dog to the workplace and into my department. I approve this request, subject to employee following these and other departmental guidelines and demonstrating responsible dog ownership. _____________________________________________________ NAME

__________________ DATE