Emotional Support Animal Request Form

Please submit this form to request the accommodation of an Emotional Support Animal in Campus Housing.

Student First Name (preferred)

Student Last Name

Student Legal Name (if different from preferred)

Pronouns

he/him/his

she/her/hers

they/them/their

Student ID#

E-Mail Address

Phone Number

When will you first need this accommodation?

Summer 2024

If you intend to adopt an animal to serve as your Emotional Support Animal (ESA), and therefore do not have the details about the animal which are requested below, please leave those items blank. The Disability Resource Center will work with you after your request is reviewed to discuss the specific animal you intend to adopt if it is determined that an ESA is an appropriate accommodation for you.

Animal Name

Type/Breed of Animal

Age of Animal

Describe how an emotional support animal would impact your ability to fully participate in the University Housing program.

Please provide the name and contact information of who the University may contact to care for your animal in the event of an emergency. Please note this individual may not be a resident in University Housing.

Documentation Attach supporting documentation from your health provider.

I understand that the Disability Resource Center may communicate with University Housing about my accommodation request.

Signature

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