Housing Accommodation Application and Consent Form

Name

Phone

Accommodation(s) Requested

Emotional Support Animal

Service Animal

Meal Plan Exemption

Meal Plan Reduction

Other…

Additional Information or requests

I understand that by signing this form I am giving the Housing Accommodations Committee of East Texas Baptist University consent to consider my accommodation request and discuss my documentation. In addition, if I am granted accommodations, I give the ETBU Housing Accommodation Committee permission to notify relevant faculty or staff of my approved accommodations.

Digital Signature

Sign above

For Meal Plan Reduction or Removal application, please make sure you attach a doctors note from a licensed healthcare provider.

For ESA application, please make sure you attach the following,

ETBU Healthcare Provider form (completed by a licensed Healthcare Provider), email desieraeb@etbu.edu for access to this form.
An up‐to‐date copy of the ESA’s immunizations.
A current photo of the animal.
The veterinarian’s report indicating your animal has been spayed or neutered.
Proof of renter’s or homeowner’s liability insurance to cover any damage caused by the animal.

Please upload any relevant files or documentation here. (IEP, 504 Plan, Documentation of Disability, etc.)

Unlimited number of files can be uploaded to this field.
100 MB limit.
Allowed types: gif jpg jpeg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip.