Emotional Support Animal Application

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID:
Hint: Enter 7 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).

Contact Information

Local Address

Permanent Address Same as Local Address

Are you requesting an Emotional Support Animal in your residence?

Yes

No

Additional Note or Comment
Please describe the Emotional Support Animal you are requesting.
Describe your understanding of how your disability impacts living at San Juan College and what symptoms will be reduced by having an ESA.
Is your condition temporary or permanent? * (Selection is Required)

Temporary

Permanent

Additional Note or Comment
Are you an incoming first year or returning student? * (Selection is Required)

First year student

Returning student

Additional Note or Comment
Do you have a current SJC housing assignment? * (Selection is Required)

Yes

No

Additional Note or Comment

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