Emotional Support Animal Request Form

In order to process your ESA accommodation, the DRC requests the following documentation:

1. Completed Intake Form

2. Completed Housing Medical Accommodation Request Form

3. Letter of Support from Medical/Healthcare Provider (see detailed description in Medical Accommodation Request Form)

Please note that while your Emotional Support Animal may be permitted in Housing while you go through the registration process, you are still responsible for following Housing and FIU guidelines for ESAs on campus and may be subject to repercussions for Code of Conduct violations.

Once your initial documentation is approved, the DRC will send the request to Housing and a representative will reach out to you to submit vaccination records for your ESA, a photo of the animal, roommate approval, and other registration forms.

If you have any questions, please contact Stephanie Bello at smbello@fiu.edu.

Name Name * First Last
Panther ID *
FIU Email *

Confirm Email Address *
Phone Phone * - ### - ### ####
Type of ESA *

Type of ESA Dog Cat Other (please specify) Other (please specify)
Campus *

Campus Modesto Maidique Campus (MMC) Biscayne Bay Campus (BBC)
I am interested in learning more about receiving academic accommodations: *

I am interested in learning more about receiving academic accommodations: Yes No

If you decide at a later time that you would like to receive academic accommodations, you may reach out at any time via email at drc@fiu.edu or phone at 305-348-3532 to schedule a consultation.
I require an ADA room accommodation (such as private room, private bathroom, private suite). I am providing supporting documentation for this request below. *

I require an ADA room accommodation (such as private room, private bathroom, private suite). I am providing supporting documentation for this request below. Yes No

Please upload a letter from a physician, medical/mental health provider supporting your need for ADA housing accommodations.
Please download and complete the following forms. You will then submit the forms in the file upload section below.
Student Intake Form
Medical Accommodation Request Form
1) Student Intake Form *

Attach Files
2) Medical Accommodation Request Form *

Attach Files
3) Physician Letter of Support *

Attach Files
By signing this form, I understand that:
- The statements I make in this request are true and accurate to the best of my knowledge.

- Any evidence of fraud or misrepresentation in this process will result in the automatic recommendation for a denial.

- I will follow all ESA guidelines in Housing while my ESA application is in process or be subject to disciplinary action.

- My ESA cannot be anywhere on campus other than my assigned room and designated area for animals in Housing. *
Must be 7 characters. Currently Entered: 17 characters.
I understand this is a legal representation of my signature.
*Please allow 5-7 business days for your request to be processed by DRC and sent to Housing for review.

Once submitted, be prepared to submit vaccination records, a clear photo of the animal, in addition to ESA Housing registration forms. You will be contacted by Housing to set up a meeting to discuss an approval determination and go over responsibilities and guidelines for your ESA in Housing.

Housing may deny a reasonable accommodation request for an emotional support animal if such animal poses a direct threat to the safety or health of others or poses a direct threat of physical damage to the property of others (such as reptiles), which threat cannot be reduced or eliminated by another reasonable accommodation.

Emotional Support Animal Request Form

Emotional Support Animal Request Form

Please download and complete the following forms. You will then submit the forms in the file upload section below.

Student Intake Form

Medical Accommodation Request Form

By signing this form, I understand that: