-
-
TO BE COMPLETED BY MEDICAL OR MENTAL HEALTH PROVIDER:
-
-
-
-
-
-
-
-
-
Does the student have a physical or mental impairment which substantially limits one or more major life activities?
-
Please check which of the following major life activities are impacted by the student's disability:
-
-
Does the service/ emotional support animal perform work or do tasks for the student because of his/her disability?
-
-
Is the animal necessary to provide the student with an equal opportunity to use & enjoy his/her campus residence?
-
-
-
-
-
-