Accessibility Resources- ESA Student Request Form

Assistance Animal Student Request Form

Assistance Animal Health Professional Acknowledgement

An Assistance Animal accommodation request cannot be reviewed without the Assistance Animal Health Professional Form. It is the student’s responsibility to provide this form to the appropriate professional for completion and to include it with the request.

Assistance Animal Health Professional Acknowledgement

I acknowledge I have a completed Assistance Animal Professional Form to include with my request

1. Student's Full Name:

2. Email:

Please enter your UC email address. Approval decisions will ONLY be communicated via UC email accounts.

3. UCID:

4. M#:

5. Phone number:

6. Campus Housing Address:

7. Current Student Status

Incoming Student (Freshman or Transfer)

Returning Student

Other...

8. For what disability are you requesting an Assistance Animal?

9. What are your current symptoms and how are they/will they impact your ability to have equal access to UC's residential community?

10. Explain why an Assistance Animal is necessary to manage your symptoms.

11. What strategies do you currently use to manage your symptoms?

12. If approved, when do you want the accommodation to begin?

Current Semester

Next Semester

Other...

13. Please share any additional information you would like to provide.

14. Assistance Animal Health Professional Form Upload

Please upload your completed Housing Accommodation Assistance Animal Health Professional Form.

15. Additional uploads:

Upload any additional documentation, assessments, etc. in support of your housing accommodation request.

Assistance Animal Student Request Form

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