ESA Request - Required Forms
If you are requesting an ESA on campus, please complete the following form and submit for review.
Student Name
*
First Name
Last Name
FSC ID Number
*
Mocs Email
*
example@mocs.flsouthern.edu
Phone Number
*
Please enter a valid phone number.
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Disability Documentation Guidance Form
This form is to be completed by the healthcare professional.
Please download the guidance form, provide it to your healthcare professional, and upload the completed form below.
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Professional ESA Request Form
This form is to be completed by the healthcare professional.
Please download the request form, provide it to your healthcare professional, and upload the completed form below.
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Professional's Letterhead Diagnosis & Recommendation
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Student ESA Accommodation Request Form
This form is to be completed by the student requesting an ESA on campus.
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Consent Waiver
By signing this consent form, you are authorizing Student Disability Services to send a description of your approved academic accommodations to your course instructors and academic advisor, and your residential accommodations to Community Living, Campus Safety, and other need-to-know community members. For academic accommodations, it is your responsibility to discuss with your instructors how the accommodations will be implemented in the classroom. If you make changes to your schedule after you sign this consent waiver, please notify us so that your new instructors can be informed as soon as possible. A signed Consent Waiver will allow the Office of Student Disability Services to release your accommodation information for the 2023-2024 academic year. You are responsible for contacting SDS if you would like to REVOKE permission for accommodation information to be sent.
If you are seeking an Emotional Support Animal/Service Animal/Service Animal In Training, you agree that we may release this information to roommates/suitemates, Community Living, Campus Safety, and other community members who may need to know that this accommodation is being sought or has been approved.
*
Yes
No
Please provide contact information of any other person(s) you are permitting to receive information about your accommodations:
Date
*
-
Month
-
Day
Year
Date
Signature
*
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