Service Animal Registration Form

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.

Date of Arrival on Campus (mm/dd/yyyy)
Date Format: MM slash DD slash YYYY
Date of Departure from Campus (mm/dd/yyyy)
Date Format: MM slash DD slash YYYY
Full Name
First Last
Residence Hall Bldg. & Room
Cell Phone Number
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Status on Campus
Name of Animal
Breed/Type of Animal
Sex of Animal
Is the length of time the animal will be on campus is 7 days or less?
- Yes
- No
Identifying tags or Accessories
State of Licensure
Date of Most Recent Vaccinations (mm/dd/yyyy)
Date Format: MM slash DD slash YYYY
Maintenance Plan
Other Maintenance Plan Details
Other Important Information
Comments
This field is for validation purposes and should be left unchanged.

Wesley College

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Service Animal Registration Form