Registry for Service Animals

Date of Arrival on Campus (mm/dd/yy)
Date of Departure from Campus (mm/dd/yy)
Full Name
Campus Residence Bldg. & Room
Campus Phone
Home Address
City
State
Zip
Home Phone
Cell Phone
Email
Status on campus
Name of animal
Type of animal
Services animal provides
If the length of time the animal will be on campus is 7 days or less, you do not need to complete the rest of this form. Please continue if the animal will be on campus more than 7 days. If a service animal will be used on campus for more than 7 days, submit documentation of the disability requiring this accommodation along with this registration form.
Information about the Service Animal:
Identifying tags or accessories:
Date of most recent vaccinations (mm/dd/yy)
Training agency (Send copy of certificate to Disability Services, Box 3019)
Maintenance plan
Other important information