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ESA Application


This form must be completed PRIOR TO the Office of Residence Life review of the student’s request and PRIOR TO the animal arriving on campus. The student requesting the accommodation must complete this form.

Prior to completion of this form, please review the all information provided below.

ESA Procedure and Request Criteria

To request a reasonable accommodation for an Emotional Support Animal (ESA) through the Office of Residence Life, an individual with a disability must have a licensed physician or mental health professional complete the "ESA Verification Form.” Copies of the Verification Form can be obtained from the Office of Residence Life. 

· The University of Pikeville (UPIKE) welcomes and will review requests for reasonable accommodations in its housing at any time. To ensure prompt consideration of such requests, individuals seeking accommodation must submit the completed Verification Form to the Office of Residence Life at UPIKE as soon as possible before moving into University housing. Please note that if a request is made less than 60 days before the intended move-in date, UPIKE cannot guarantee that the individual's accommodation needs will be met during the first semester or term of occupancy. 

· If an individual already resides in UPIKE housing and requires an ESA, they should contact the Office of Residence Life and submit the ESA Verification Form as soon as practicable. However, UPIKE cannot guarantee that it will be able to meet the accommodation needs during the semester or term in which the request is received. 

· The ESA Verification Form must be completed by a licensed third party, typically a treating professional in Kentucky or the student's home state, who can verify that the requested accommodation is necessary to provide the individual with equal access to and enjoyment of university housing at UPIKE. 

· If the third-party verification is returned without sufficient information for Residence Life to determine whether an accommodation is necessary, the Director of Residence Life will notify the individual in writing of the verification's insufficiency and may request additional information, including speaking directly with the third-party verifier.

Additional Information & Documents to Attach Below:

· Veterinarian Assessment of the animal bree/mix of breed

· Clear and current photograph of the animal

· Record of vaccinations

· Verification that the animal has been spayed/neutered

Background Information

 
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Room Number

Involved Parties

Involved party 1

Questions

Please carefully review and respond to each statement and question below. 

University housing may require the assignment of roommates and/or that individuals share a room or suite in certain residence halls. Therefore, to ensure that the presence of an ESA is not an undue administrative burden or fundamental alteration of university housing, UPIKE reserves the right to assign or reassign an individual with an ESA to a different room and or building. However, the Office of Residence Life shall consult with Disability Resource Center (DRC) and the Office of Compliance and Legal Affairs for all ESA requests to determine on a case-by-case basis whether the animal's presence is reasonable. UPIKE may consider various factors, such as but not limited to the animal's crate size, financial and/or administrative burden, impact on university housing policies, allergies of other individuals, noise disturbance, housebreaking, vaccination, health risks, safety concerns, aggressive behavior, and excessive damage to housing,(Required)
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UPIKE has determined that the residence hall environment is generally not appropriate for raising young puppies. Generally, dogs must be at least 10 months old, and cats must be 5 months old, spayed or neutered, and up-to-date on vaccinations before they can live in university housing. In most cases, UPIKE will approve the presence of only one ESA per student and one ESA per room.(Required)
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If UPIKE approves an Owner's request to live with an ESA, the Owner assumes sole responsibility for the custody and care of the animal, and must fulfill all requirements of the Owner/Student as listed in the ESA Guidelines and Agreement Policy.(Required)
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If UPIKE determines that an animal in University Housing or the owner of the animal is not in compliance with the ESA Guidelines and Agreement policy the Owner/Student may be required to remove the animal with out advanced notice. If such a determination is made the Owner/student must comply within 48-hours or the University may have the animal removed to the nearest appropriate animal shelter. If an ESA is removed from the premises for any reason, the Owner must still fulfill their housing obligations for the remainder of the housing agreement.(Required)
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Is the animal Housebroken(Required)
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To your knowledge, has the animal ever been aggressive toward or bitten you or another individual or animal?(Required)
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Emergency Contact Information: I understand that in the event that the student experiences a personal emergency or is unable to care for the animal for any reason, an emergency contact must be identified. This contact must be someone who would arrive to retrieve the animal from campus within 3 hours of notification from the University. These individuals MAY NOT be another student who resides on campus.(Required)
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I understand that all information I provide must be true and accurate. If I am found to have provided any false information, the matter may be referred to the Office of Student Conduct.(Required)
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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission