Emotional Support Animal Request Form

Dear Student, The Director of Student Success ensures emotional support animals are appropriately granted to students who qualify as having a documented disability.

The process to formally declare a disability and to request an emotional support animal is outlined below. If you have further questions about the process, please contact 434.791.5754 or email eschlauch@averett.edu.

Important Note: All documentation for the fall semester is due by August 1st and December 1st for the spring semester.

Process:

  1. Self-Identify as having a disability.
  2. Submit Emotional Support Animal Request Form (current form) to the Director of Student Success.
  3. Submit current, thorough professional healthcare provider documentation:
    • The person’s health care provider, who is familiar with the professional literature concerning the assistive and/or therapeutic benefits of assistance animals for people with disabilities, must submit a signed, legibly handwritten letter on professional letterhead, expressing the following:
      • The provider’s diagnosis of the person’s condition.
        • The prover should provide both a license number and a diagnostic code.
      • The provider’s opinion that the condition qualifies as a disability under federal law, including the major life activities which are substantially limited by the disability.
      • Any additional rationale or statement the University may reasonably need to understand the basis for the professional opinion.
      • The provider must give her/his professional opinion of how the person’s documented disability relates to the necessity of the animal’s presence in the campus living units.
      • The provider’s description of what functions(s) the animal will specifically provide.
        • Examples of a “health care provider” may be a therapist/counselor, psychologist, psychiatrist, primary care doctor, or nurse.
  4. In addition to the above documentation from a health care provider, the person must provide the following documentation before being considered for the accommodation of an emotional support animal:
    • Completed Housing and Residence Life Accommodation Request Form by your Treating Physician or Counselor (5 visits or more)
    • Record of License & Registration in Danville, VA (for canines only)
    • Record of up-to-date and complete vaccinations
    • Record of current veterinarian clean bill of health
      • The animal should be free from fleas, tics, salmonella, and other infectious threats, and the submitted veterinarian documentation should reflect this.
    • Signed statement of acknowledgement of the Emotional Support/Comfort Animal Policy
    • Completed form of identification of Emotional Support/Comfort Animal and Emergency Contact/Alternate Caregiver of Animal
  5. Upon review of documentation, eligibility for accommodations will be determined (based on the documentation provided, and on a case-by-case basis) by a committee consisting of the Director of Student Success, the Director of Housing and Residence Life, and the Assistant Director of Housing Operations.
  6. If it is determined that a qualifying disability exists, the coordinator shall meet with the person requesting that emotional support animal.
    • Policy will be carefully reviewed with the person at that time, and an interactive dialogue will take place to determine whether or not the animal is a reasonable accommodation, considering alternative accommodations and the impact of the animal in the Averett University housing program.
  7. Student will be notified of the final decision (approval or denial of the emotional support animal) via student email.
  8. If an emotional support animal is approved, the student is responsible for meeting with both the Director of Student Success and the Assistant Director of Housing Operations to review the Emotional Support Animal Policies, which includes firm guidelines regarding care and supervision of the animal.

Academic Support coordinates and provides a variety of services for students with disabilities. Students with a documented disability are eligible for reasonable accommodations under the Americans with Disabilities Act (ADA) and /or Section 504 of the Rehabilitation Act of 1973. All information is confidential.

Important Notes:

  • Each request requires a minimum of 30 days advance notice to gather, review, and verify the necessary documentation prior to making a determination regarding the emotional support animal.
  • The required documentation may be mailed, scanned/emailed, faxed, or delivered in person to the Director of Student Success.
  • Information provided is confidential and will not be released to outside parties or agencies without the signed consent of the student.
  • As an institution, we consider a Treating Physician or Counselor to include at least 5 visits or more with that same licensed professional.
  • All documentation for the fall semester is due by August 1st and December 1st for the spring.
Fields marked with an * are required

PERSONAL AND ACADEMIC INFORMATION

DISABILITY DECLARATION AND INFORMATION

I wish to declare a documented disability that substantially limits one or more major life activities and make specific accommodations necessary for me to achieve access while attending Averett University. I agree to give the Director of Student Success and, as necessary, the Committee access to my documentation of this disability. If a disability is not obvious, I understand that appropriate professional documentation from a health care provider must be provided to substantiate the disability and need for reasonable accommodations. I understand that this information will be kept confidential with the exception that information as it relates to the need to implement approved accommodations may be exchanged with appropriate Housing and Residence Life Staff.

EXCHANGE OF INFORMATION/DISCLOSURE STATEMENT:

I certify that the information provided on this form is accurate. I understand that to be eligible for an emotional support animal as an accommodation that I must submit this completed form as well as disability documentation and medical documentation (for the emotional support animal) that can substantiate the requested accommodation. My signature authorizes the Director of Student Success to contact the health care provider who provided the disability documentation if additional information or clarification is needed to establish my disability and approve my accommodations. My signature further authorizes the Director of Student Success to contact the emotional support animal’s veterinarian who provided medical documentation if additional information or clarification is needed. Student signature also grants approval for the Director to communicate with appropriate university staff in order to expedite approved reasonable accommodations.

 

FOR QUESTIONS OR TO REQUEST MORE INFORMATION, PLEASE CONTACT:

Erin Schlauch, Director of Student Success
Email:  eschlauch@averett.edu
Phone:  434.791.5754
Address:  420 West Main Street, Danville, Va 24541

The Office of Student Success coordinates and provides a variety of services for students with disabilities.  Students with a documented disability are eligible for reasonable accommodations under the Americans with Disabilities Act (ADA) and /or Section 504 of the Rehabilitation Act of 1973.  All information is confidential.