Emotional Support Animal Request

Emotional Support Animal Request Form

Read the Policy on Service and Emotional Support Animals before continuing with this form.

Name*

First Name

Last Name

Email*

Cell Phone*

Student ID

Which quarter do you anticipate bringing an ESA to campus? *

Type of Emotional Support Animal *

Species

Breed of Emotional Support Animal*

Breed

Size/Weight of Emotional Support Animal *

Upload supporting documents from your doctor. Documentation must be current, on professional letterhead or prescription, and signed by licensed provider. SEE ESA POLICY FOR COMPLETE DOCUMENTATION REQUIREMENT. *

No File Chosen

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Emergency Contact Name. [Someone OFF CAMPUS who will care for the ESA in an emergency]*

First Name

Last Name

Emergency Contact Phone*

I certify that:*

I have read the Emotional Support Animal and Service Animal Policy that is linked above and I agree to the terms in the policy. I understand that signing this form does not guarantee approval for an ESA. If approved, I agree to yearly reassessment for my ESA. I will not leave my ESA in JPCatholic housing overnight, without me being present I will never leave my ESA over the Quarter breaks in the care of another student or resident.

I certify that the information above is correct.*

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