Child's Name _____________________________________________________________________

Grade and School __________________________________________________________________

Address ___________________________________________ Phone* _______________________
(*Required: Participants will be contacted by phone to confirm reading times.)

Parent/Guardian name, (address, phone if different than child's)____________________________________

How did you hear about this program?
Teacher | Librarian | Friend | Parent | TV | Newspaper

Does the child have:
- any fear or apprehension around animals, especially dogs? ____________

- a dog at home? ___________

Please provide any additional information the therapy team might need:
__________________________________________________________________________________

Please check the library location you wish to attend and indicate your first and second choice for a time slot. Then return this signed form to any Milwaukee Public Library at least two weeks prior to the start of the program.

I, _____________________________________________________ agree that my child will be a
                        (signature of parent or guardian)

member of the Read/Words program and will attend each week of the four week program.

Date application received at library ___________________________

Sponsored by Milwaukee Public Library and the Wisconsin Humane Society.

[end page one]

Read to Rover Consent & Release Form

Please complete and sign the following release (required):

I the undersigned parent or guardian of ___________________________________ (“Minor”) hereby consents to the Minor participating in the Wisconsin Humane Society and Ozaukee Humane Society, Inc. (the “Society”) Read to Rover Program and all of its activities and programs.  The undersigned, for himself or herself and on behalf of said Minor, does hereby absolutely and unconditionally release, indemnify, hold harmless and forever discharge the Society, its officers, directors, employees, successors, assigns, and agents, and each of them, from and against any and all claims, demands, obligations and liabilities of every nature and kind whatsoever, including, without limitation, negligence, occurring during, directly or indirectly resulting from or arising out of the Minor’s participation in Read to Rover.  As to matters covered hereby, this CONSENT AND RELEASE shall extinguish all claims, demands and rights which the undersigned or the Minor (and/or each of their heirs, successors, and assigns) has or may ever have against the parties released hereby, or any of them, for any injuries, costs or damages to the Minor occurring during, directly or indirectly resulting from or arising out of the Minor’s participation in Read to Rover whether such injuries, costs or damages are known or unknown, foreseen or unforeseen, ascertainable or unascertainable.

  _______________________________________________________________________________
                   Parent/Guardian Signature                                                                    Date 

You may use photographs, slides or video of my child for use in public service or educational materials for the Wisconsin Humane Society or Ozaukee Humane Society.

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