Required fields are marked with asterisks (*)

Domestic Animal Waiver of Rabies Vaccination Form

Vaccinating domesticated animals against rabies protects the individual animal against a virtually 100% fatal disease. Modern rabies vaccines are considered very safe and have low incidence of adverse effects. It is strongly encouraged by the Town of Stony Plain that rabies vaccinations are obtained for domestic animals; however, this form may be used as a waiver of the rabies vaccination requirement as per Section 1.4.4 of the "Responsible Pet Ownership Bylaw" (2566/AC/16). Hereinafter referred to as the "Bylaw".

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of completing the Domestic Animal Waiver Vaccination Form. If you have any questions regarding the collection, use, and disclosure of personal information, please contact the FOIP coordinator at 780-963-2151.

By signing this form, I acknowledge the below statements (initial required after each point):

First Name:

Last Name:

Domestic Animal's Name:

License No: (with year)

I take full responsibility for any injuries and associated medical and legal costs involved with the potential transmission of the rabies virus from this domestic animal to any other animal, livestock, wildllife, or human.

I understand that the Town of Stony Plain does not assume any liability in regards to the licensing of said animal and its subsequent actions.

I understand that this waiver does not exempt me from any other duties or obligations under the Bylaw.

I understand that it is strongly encouraged that, in order to minimize the risk of exposure to rabies, the domestic animal should be kept on a leash and away from other animals, including wildlife.

I understand that if my domestic animal does contract rabies, I will follow all requirements as per Section 8.0.0 of the Bylaw. This includes surrendering this domestic animal upon demand by a Peace Officer for supervised quarantine.

I understand that the expenses for supervised quaratine shall be borne by me for this domestic animal's surrender to a Peace Officer who has reasonable and probable grounds to suspect it of having been exposed to rabies or any other communicable disease.

I understand that if my domestic animal is bitten by an animal adjudged to be rabid, I will be required to either treat the rabies infection at my expense under quarantine or the domestic animal will be destroyed.

Owner's Address:

Owner's Phone Number:

Owner's Signature of Understanding:

Clear

Date: