Service Animal Registration - Office of Disability Services
  1. Semester Requested For(*)
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  2. Students Full Name(*)
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  3. Students Address
  4. Address Line 1(*)
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  5. Address Line 2
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    If applicable
  6. City(*)
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  7. State(*)
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  8. Zip(*)
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  9. Residence Hall and Room Number
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    If applicable
  10. Phone(*)
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    xxx-xxx-xxxx
  11. Student Cell Phone
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    xxx-xxx-xxxx


  12. Emergency Contact Information
  13. Name(*)
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  14. Phone(*)
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    xxx-xxx-xxxx


  15. Emergency Contact #2
  16. Name
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  17. Phone
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    xxx-xxx-xxxx


  18. List Animals Most Recent Vaccinations
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  19. You have the option to meet/register with the Office of Disability Services to discuss additional accommodations/adjustments.

    I give Tennessee Tech University permission to release this information to the appropriate faculty and staff as deemed necessary. I understand that faculty in whose classes I am registered as well as campus police or other university officials may be provided with a copy of this information, and that it may be necessary to call outside assistance. I further understand that I am responsible for any expense that may be incurred as a result of my service animals presence on campus or interaction with the animal. I release Tennessee Tech University and its employees from all liability, injury, or damages occurring while the service animal is serving on campus.

  20. Initial for Students Electronic Signature (*)
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  21. Date(*)
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  22. Witness's Full Name(*)
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  23. Initial for Witness's Electronic Signature (*)
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  24. Date(*)
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  25. IF LIVING ON CAMPUS IN A RESIDENCE HALL OR TECH VILLAGE PLEASE SIGN AND DATE THE STATEMENT BELOW:
  26. Student's living on campus and utilizing a Service Animal are responsible for:
    1. Any damages incurred from the service animal.
    2. Cleaning and disposal of waste upon occurrence.
    3. All flea and other pests related to service animal.
    4. Adherence to noise policies.
    5. Adherence to all other residential life policies.
  27. Initial for Students Electronic Signature
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  28. Date
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  29. submit
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