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
How did you hear about this program?
Does the child have:
- any fear or apprehension around animals, especially dogs? ____________
- a dog at home? ___________
Please provide any additional information the therapy team
Please check the library location you wish
to attend and indicate your first and second choice for a time slot.
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
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.
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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
Photo Release (optional)From time to time the Wisconsin Humane Society and Ozaukee Humane Society use slides, video, or photographs of various educational activities. If you would be willing to allow us to use pictures of your child taken during the Read to Rover Program as part of our public service or educational materials, please indicate this by signing below.
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.
Parent/Guardian Signature Date