Service or
Assistance Animal Form

Application of Approval for Service or Assistance Animal

Name(Required)

First Last

Student ID

Phone(Required)

Email(Required)

Request For(Required)

Service Animal (Definition: An animal that has been trained to assist a person who has a disability.)

Assistance Animal (Definition: Emotional Support.)

Please Note: Assistance Animals are for campus housing only.

Type of Animal(Required)

Dog

Cat

Other

What is the breed and name of your animal?(Required)

Additional Documents

1. Proof of animal vaccination

2. Documentation from a health care provider or another qualified person which verifies the existence of a disability (without specifics on the nature of the disability) and disability-related need for the assistance animal.

Note: This application will not be reviewed until all additional documents are submitted.

Acknowledgment

Student/applicant signature signifies that the student acknowledges and agrees to abide by IVCCD Board Policy 526 Service and Assistance Animal Policy, and the guidelines set as to, but not limited to, the location, care, and control of the approved animal.

Signature

First Last

Date