In your opinion, how important is it for the student's well-being that an ESA be in residence on campus?

Have you discussed the responsibilities that come with taking good care of an animal while participating in regular college activities and living on campus? Do you believe those responsibilities might intensify the student's symptoms in any way? Please note that students are not permitted to bring in an animal prior to approval.

Name & Credentials:

Address:

Telephone:

Email:

License #:

Professional Signature:

Date:

I, ,hereby authorize the release of the following information as well as any pertinent documentation to the Accessibility & Disability Resource Center at Kentucky State University for the purpose of determining my eligibility for accommodations.

CWID:

Student’s Signature: