ESA Temporary Caregiver Designation

ESA Temporary Caregiver Designation
This agreement is intended for students who have an approved Emotional Support Animal (ESA) and need to designate another student residing in campus housing to temporarily care for their animal. The temporary care period may not exceed 7 consecutive nights. If longer than 7 nights is needed, please explain why in the notes section.The student designated as the temporary caregiver must agree to comply with all applicable regulations and requirements outlined in the ESA Policy, as agreed to by the animal’s owner. Additionally, all roommates of the temporary caregiver must consent to having the animal in their shared living space and confirm that they do not have any allergies or other health-related concerns that would be affected by the animal’s presence.

Please fill out all the information below. The temporary caregiver will receive a request email, as well as further instructions to input their roommate information.
Owner's Information
Your Name

First NameLast Name
Your W Number
Your WNMU Email
example@wnmu.edu
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
ESA Description
Type of animal and appearance (e.g. white cat, brown dog)
ESA Name
Starting Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat day will your designated person begin watching your animal?
Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat day will the animal be returning to your care?
Notes
Temporary Caregiver's Information
Their Name
Their W Number
Their Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Their WNMU Email
example@wnmu.edu
Their Residence Hall
Their Room Number
Should be Empty:

ESA Temporary Caregiver Designation

Owner's Information

Temporary Caregiver's Information