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 verify that I have read and understand the College’s Service Animal Policy and will abide by its requirements.

Handler’s Name	Date

Signature

Fed law/ADA/service animals/registration form 3-6-12-#t