Requesting an Emotional Support Animal

The student should obtain appropriate documentation for the request of an ESA from a healthcare provider who is aware of the student's condition and with whom they have a professional relationship. Written or printed document must be on official letterhead which includes the address, telephone number, name, title, and professional credentials of the evaluator. All typed documents must be accompanied with an official letterhead.

• Disability records that are no older than 3 years must be supported by an official letterhead from a medical or mental health practitioner. The doctor or mental health professional must sign and date the paperwork.
• No ESA weighing more than 25 pounds (11 kg) will be accepted, and documentation must include the animal's name, weight, kind, color, and how it would emotionally assist the student.

NOTE: To be considered, all applications must contain the following completed documentation at the time of submission and be sent by email to Nubia.Baraka@kysu.edu.

Student Information

Student Information

Full Name:

CWID:

Date:

Present Academic Status: (Circle One)

First Year Second Year Third Year Other

Animal Name:

Animal Type:

Male or Female:

Breed Description, Age, Weight, etc.: