Disability Support Services
Service and Support Animal Accommodation Form Please review the University’s Service and Support Animal Policy prior to submitting this form to the DSS Team in the Learning Center. Use the separate Service and Support Animal Housing Accommodations Form to request accommodations for University Housing. Visit www.liu.edu/about/university-policies/service-and-support-animalpolicy for more information. IMPORTANT: Submission of this form must be accompanied by a veterinarian’s verification that the animal has all veterinary-recommended vaccinations to maintain the animal’s health and prevent contagious disease. Also include a copy of New York’s required animal license (for dogs only).
Student Information Name:
LIU ID Number:
Phone Number:
LIU Email Address:
Address Line 1: Address Line 2: City:
State:
Zip Code:
Animal Information Name:
Type of Animal:
Physical Description of Animal (i.e., size, weight, etc.):
Alternate Caregiver (if owner is unavailable) First Name:
Last Name:
Phone Number:
Email Address:
Policy Agreement
By my signature below, I verify that I have read, understand, and will abide by the Guidelines outlined in the University’s Service and Support Animal Policy and I agree to provide the additional information required to complete my Request for a Reasonable Accommodation under the University’s Service and Support Animal Policy. Student Signature:
Date:
Learning Center www.liu.edu/learningcenter LIU Brooklyn, Global, and Hudson Campuses LIU Brooklyn, Library Learning Center, 4th Floor Phone: 718-488-1095 Email: Bk-learningcenter@liu.edu
LIU Post and Riverhead Campuses
LIU Post, B. Davis Schwartz Library, 1st Floor Phone: 516-299-3057 Email: Post-learningcenter@liu.edu