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Emotional Support Animals Application

Students requesting an accommodation for an emotional support animal must complete this application. In addition, a separate form needs to be completed by the qualified professional who diagnosed the condition and who supports the accommodation requested. No accommodation will be approved until all forms have been completed and received by the Accommodation Committee. Please note this information is confidential, and will only be shared with members of the Student Accommodations Committee as they consider their request. This COMPLETED form is due November 25, 2016 for current incoming Becker College Students (Spring '17 Semester), March 2017 for current Becker College Students (Fall '17 Semester), June 2017 for incoming Becker College Students (Fall '17 Semester)
  • I certify that all information within this application is accurate and complete and does not misrepresent my present condition. I understand that members of the Student Accommodations Committee may contact my diagnosing physician or other qualified professional for clarification of my condition and recommended accommodations.
    I authorize the Accommodations Committee to discuss, either in writing or orally, my accommodation(s) with appropriate administrators, faculty members, staff members, and/or third-party service providers on a limited, need-to-know basis for the purpose of providing and/or coordinating accommodations and services for me.
    I understand that every request for accommodations is evaluated individually based on the submitted documentation and suing the same criteria.