Support Animal Form

Forms that need to be submitted for Approval of Support Animals in Wagner College Housing

Disability Housing Accommodation Request – to be completed by the student .
Disability Request For Information Re: Support Animal –To be completed by licensed medical professional who is not (a) a relative of the student and/or (b) an employee of the Wagner College Center for Health & Wellness, Nursing Program, or any other affiliated office.

Documentation of the need for a Support Animal should follow the Medical Housing Documentation Guidelines and should generally include the following information:

Verification of the individual’s disability from a licensed physician, psychiatrist, psychologist, social worker or other mental health provider.
A statement on how the need for the animal relates to the ability of the resident/student to use and enjoy the living arrangements provided by the college

Support Animal Request Form

This form should be completed by the student! In order to request a Support Animal, the additional documentation form is required for the application to be processed.
Section I: Demographic Information
Student First Name*
Student Last Name*
Student Preferred Name*
Student ID Number*
Student Wagner.edu Email Address*
Student Phone Number*
Date of Birth*
Gender Assigned at Birth*
Gender Identity or Expression*
Current Class Year*
Anticipated Graduation Date*
Anticipated Graduation Date*
Section II: Accommodation Request Information
Are you a returning housing accommodation applicant or a new accommodation applicant?
If you currently have a medical housing accommodation and are renewing your application, you may need to have a physician complete the Housing Accommodation Documentation Form. If you are submitting a new application for a medical housing accommodation, please make sure your physician completes the Service & Support Animal Information Request form in order for your request to be reviewed.
Current Housing Assignment (if applicable):
Do you have a physical or mental impairment?*
Does/Do your Impairment(s) substantially limit at least one major life activity or major bodily function?
Does the animal(s) provide therapeutic emotional support to alleviate a symptom or effect of the disability condition(s)? If so, how?
Describe the type of support animal you are requesting?
How will the support animal help address the specific condition?
Have your registered any of these conditions with Accessibility Services?
Have your registered any of these conditions with the Center for Health & Wellness?
Section III: Final Review & Submission
Please review and initial the following statements:
I understand that Support Animals are not guaranteed in specific buildings, or in specific types of living (singles, doubles, suites). I understand that requests and living spaces are analyzed on a case by case basis.
I understand that students who do not have conditions registered with Accessibility Services and/or Health & Wellness will be encouraged to do so.
I understand that I may be asked to come to a meeting to discuss the condition and potential accommodations.
By submitting this form, I do hereby authorize the disclosure of information on a need to know basis to college employees and specifically authorize the following individuals to share relevant material and communicate regarding my Housing Accommodation Request: Center for Health & Wellness (designee), Office of Academic Advising and Accessibility (designee), and Office of Residential Education (designee).
Purpose of and need for disclosure: Housing Accommodation Request. This authorization may be revoked by me in writing at any time except of the extent that action has been taken already in response to this Consent for Disclosure of Information or Records or there are pending issues related to such. I am aware that information from my records is confidential and protected by Federal and State Law. NOTE: If this is your first time requesting a Housing Accommodation (or if there has been a change in your condition that affects your request), you will also need to have the Documentation form completed by your healthcare provider.
Name
This field is for validation purposes and should be left unchanged.

Request for Information Regarding Support Animal

Please print this form and give it to your health care provider. They should return the completed form to Accessibility Services at Wagner College.

Request for Information- Licensed Medical Professional

Support Animal Form

Forms that need to be submitted for Approval of Support Animals in Wagner College Housing

Support Animal Request Form

This form should be completed by the student! In order to request a Support Animal, the additional documentation form is required for the application to be processed.

Section I: Demographic Information

Section II: Accommodation Request Information

Section III: Final Review & Submission