Application for Emotional Support Animal
Briar Cliff University | Office of Residence Life
Student Information
Name
*
First Name
Last Name
Student ID
*
Residence Hall & Room Number
*
Emergency Contact
This person must not be another BCU resident who resides in university housing.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship
Emotional Support Animal Information
Only one ESA per student.
Species of Animal
*
Dog
Cat
Gerbil
Rabbit
Guinea Pig
Other
Breed of Animal
Sex of Animal
*
Female
Male
Age of Animal
*
Date of Spay/Neuter
*
-
Month
-
Day
Year
Date
Are You the Owner of the Animal
*
Yes
No
Length of Ownership
*
Name of the Animal
*
Required Documentation
Briar Cliff University Emotional Support Animal Provider Documentation
*
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Licensed Health Care Provider Official Referral Letter
*
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Emotional Support Animal Veterinary Documentation
*
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Briar Cliff University Emotional Support Animal Roommate Agreement Form
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Emergency Contact Consent for Emotional Support Animal
*
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Clear, Full-Bodied Photograph of the Emotional Support Animal
*
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Emotional Support Animal Agreement
I have read, understand, and agree to abide by the guidelines regarding the Emotional Support Animal Policy for Briar Cliff University.
Signature
*
Submit
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