Fillable Esa Service Animal Request (Jacksonville University)

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Esa Service Animal Request (Jacksonville University)

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JACKSONVILLE UNIVERSITY
Disability Support Services
2800 University Blvd. N.
Jacksonville, FL 32211
Phone: (904) 256-7067 -- Fax: (904) 256-7066
Documentation Guidelines
Welcome to the office of Disability Support Services (DSS) at Jacksonville University (JU). To be
eligible for services at the DSS, a student must satisfy the definition of a disability as established
by the Americans with Disabilities Act of 1973. Section 504 defines a disability as a
condition which substantially limits one or more major life activities such as
learning, walking, seeing, hearing, breathing, caring for oneself, and working. To
be eligible for accommodations, a student must provide appropriate documentation of each
disability that demonstrates an accompanying substantial limitation to one or more major life
activities.
The following guidelines are provided in the interest of assuring that professionals’ statement is
appropriate to document eligibility for support services. The student with a disability must
provide the office of DSS appropriate written documentation from a licensed professional in the
field concerning the specific diagnosis and expected academic limitations.
To be filled out by the student:
I, ____PRINT___________, hereby authorize the following information as well as any
other pertinent documentation to be forwarded to the office of Disability Support Services at
Jacksonville University for the purpose of determining my eligibility for accommodations.
Student’s Signature:
Date:
Student JU ID Number:
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Application for Requesting a Medically Required Service or
Emotional Support Animal
This documentation must be completed and signed by the medical professional who has
prescribed the accommodation.
Student Name: _____________________________
Date: ____________________________________
With prior approval, a student with a disability may have a medically required service or
assistance animal within the residence hall as a reasonable accommodation.
1. The request must be made in advance to the Disability Support Services Office, to allow for a
thorough review. The request should be made at the point that the housing deposit is submitted
(for incoming students), or prior to the first week of class (for continuing students).
2. This form must be completed by a licensed medical professional (i.e. Mental Health
professional, Psychologist, Psychiatrist, or Physician/Doctor.) who has provided treatment for
the disability.
A. Evidence of the disability and the diagnosis related to the need of service or
assistance animal
1. Diagnosis:
2. Date at which the diagnosis was first made:
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3. Dates of treatment:
4. Symptoms for which treatment was needed:
B. Evidence of the connection between the diagnosis/symptoms and the need for a
service or emotional support animal. What service/function does the Service
and/or emotional support animal provide to the student?
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Professional Signature:
Print Name, Title, Degree:
Professional License Number:
Contact Information:
Thank you for your prompt response to this request. Please return this information to:
Olga L. Florez, M.Ed., M.P.A
Director, Disability Support Services
Davis Student Commons, 3
rd
floor
Division of Student Affairs
2800 University Blvd. N.
Jacksonville, FL 32211
Email: oflorez@ju.edu
Phone: (904) 256-7067 -- Fax: (904) 256-7066
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Esa Service Animal Request (Jacksonville University)

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Completed 24 July 2020

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