Assistance Animal Request Form

The �� is committed to supporting students with disabilities by allowing Assistance Animals (AAs) when an Assistance Animal is necessary for them to be able to use and enjoy their residential living space. The Assistance Animal (AA) Policy applies to all students and explains the specific steps necessary to request an assistance animal at The ��.

The American with Disabilities Act (ADA) defines a person with a disability as someone who has a physical or mental impairment that substantially limits one or more major life activities. The three factors influencing a determination of substantial limitation are 1) the nature and severity of the impairment, 2) the duration or expected duration of the impairment, and 3) whether the impairment is characterized as permanent or long-term. Assistance Animal is defined as an animal that is necessary to afford the student with a disability an equal opportunity to use and enjoy UNA owned, operated, or managed housing, and provides emotional or other support that ameliorates one or more identified symptoms or effects of a person’s disability. Unlike service animals, assistance animals are not required to be trained to perform work or tasks.

The requesting student (handler) must complete the information on this form and submit to Housing and Residence Life (HRL). Any form that is not completed according to the directions or in full will not be processed.

- indicates required field

First NameLegal Name

Middle NameLegal Name

Last NameLegal Name

UNA ID NumberPlease use the following format: L00XXXXXX (8 Digits)

Cell Phone Number

UNA Email Addressusername@una.edu

Assigned Residence Hall or Apartment

Apartment or Room Number

Current Academic Classification

Term or Year Requesting

Type of Animal Requested

If Other, Please Describe

Requested Animal BreedPlease be specific.

Requested Animal Name

Requested Animal General Height

Requested Animal General Weight

Has the animal been spayed or neutered?

Primary Emergency Contact for Assistance AnimalPlease include the full name, phone number, email, and current address.

Secondary Emergency Contact for Assistance AnimalPlease include the full name, phone number, email, and current address.

Please upload a copy of the veterinarian health report for the requested assistance animal. Valid files are: JPG, PNG, PDF, DOC, DOCX, PPT, PPTX, XLS, and XLSX

I have read and understand the Assistance Animal Policy and Agreement, and I agree to abide by the requirements applicable to Assistance Animals. I understand that if I fail to meet the requirements set forth in the policy, the University has the right to remove the assistance animal, and I will be required to fulfill my housing, academic, and all other obligations for the remainder of the housing contract. I furthermore give permission to the ��, through appropriate personnel, to disclose to others impacted by the presence of my emotional support animal (Housing and Residence Life staff, University Police Department, Facilities, potential or actual roommate(s)/neighbor(s), etc.) that I will be living with an animal as an accommodation. I understand that this information will be shared only with the intent of preparing for the presence of the assistance animal and/or resolving any potential issues associated with the presence of the assistance animal. I further recognize that the presence of the assistance animal may be noticed by others visiting or residing in University housing and agree that staff may acknowledge the presence of the animal, and explain that under certain circumstances assistance animals are permitted.

By my signature below, I give my consent for the Assistance Animal Review Committee to contact my treating professional for additional information as needed. Any such discussion will focus on the disability related to this request only. I also acknowledge the terms set forth above and agree to the release of information as described.

Please make sure all required fields have been filled out correctly.

Your Assistance Animal Request Form has been submitted. Your request will be reviewed once all documentation has been received by Housing and Residence Life. Please check your UNA Email regularly for status updates.

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Assistance Animal Request Form

Acknowledgement and Release of Information Consent Form

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Assistance Animal Request Form

Acknowledgement and Release of Information Consent Form

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