Emotional Support Animal Request Form

Emotional Support Animal Request Form

Accessibility Services
Student/Owner Information
Student's Name:*

First NameLast Name
S#:*
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Student Email:*
example@example.com
Permanent Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residence Hall:*
Room Number:*
Animal Information
Name of Animal:*

First NameLast Name
Species:*
Breed:*
Color:*
Age:*
Sex:*
Level of training:
Services animal provides to student/owner:
Documentation for ESA:
In order to be approved to have an Emotional Support Animal (ESA) in the residence hall, the following docummentations must be submited, along with documentation from a certifed medical provider. In addition to completing and submitting all required documentation, students must set up a meeting with the Residence Hall Manager for final approval.

Failure to submit all four forms of documentation, including the documentation from a certified medical provider, will result in a denial of the ESA request. Final approval will be complete after all the required documentation is gathered and the student schedules a meeting with the Residence Hall Manager.
Records of up to date animal vaccines:*

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Record of current veterinarian clean bill of health:*

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Completed form of identification of ESA and emergency contact:*

Cancelof
A clear picture of the animal (front view showing the face and side view showing head to tail):*

Cancelof
Should be Empty:

Student/Owner Information