Fillable VOLUNTARY SERVICE ANIMAL REGISTRATION FORM LEARNING ACCOMMODATIONS CENTER (Northern Essex Community College)

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VOLUNTARY SERVICE ANIMAL REGISTRATION FORM LEARNING ACCOMMODATIONS CENTER (Northern Essex Community College)

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The VOLUNTARY SERVICE ANIMAL REGISTRATION FORM LEARNING ACCOMMODATIONS CENTER (Northern Essex Community College) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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VOLUNTARY SERVICE ANIMAL REGISTRATION FORM
Service Animal Handler Information
Name:
Address:
Phone Number: Email:
College ID #:
Please check status: Student □ Employee □ Visitor □
Service Animal Information
Animal’s Name:
Type of Animal and Breed:
Physical Description of Animal:
State of Licensure and License Number:
Veterinarian: Phone #:
Recent Vaccination and Immunization History:
Service Animal Eligibility Information
Is the animal required because of a disability? YES________ NO_________
What work or task is the animal trained to perform?
I verif
y that I have read and understand the College’s Service Animal Policy and will abide by its requirements.
Date Handler’s Name
Signatur
e
Fed law/ADA/service animals/registration form 12-9-15
100 Elliott Street, Haverhill, MA 01830
Tel: 978-556-3654
Fax: 978-556-3168 email: lacenter@necc.mass.edu
LEARNING ACCOMMODATIONS CENTER
www.necc.mass.edu/learningaccommodations
Behrakis One-Stop Student Services Center, SC111
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VOLUNTARY SERVICE ANIMAL REGISTRATION FORM LEARNING ACCOMMODATIONS CENTER (Northern Essex Community College)

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Completed 17 September 2020

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