RBC Emotional Support Animal Request Header Image

Requestor Information

This is your Richard Bland College R-Number
Name*
Please use your Richard Bland College email address
Please enter a phone number where you can be easily reached

Accessibility Specific Information

(550 max characters)
(550 max characters)
(550 max characters)
(550 max characters)
(550 max characters)

Documentation Instructions: 

You must upload the following documents to support your request. Failure to upload all required documentation could result in delay and/or denial of this application.

  1. A letter of support from the medical professional treating for the particular diagnosed condition
  2. A completed Healthcare Provider Assessment Form verifying the diagnosed condition. Please select the form that applies to you:
    • a. If the diagnosed condition is psychologically-based, choose this form
    • b. If the diagnosed condition has a physical or medical basis, choose this form


Support Letter*
No File Chosen
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A letter of support from the provider treating the diagnosed condition (jpg,jpeg,gif,png,bmp,tif,pdf,doc,docx)
Completed Healthcare Provider Assessment*
No File Chosen
File uploads may not work on some mobile devices.
Download the appropriate form as explained in the instructions above (jpg,jpeg,gif,png,bmp,tif,pdf,doc,docx)

CTA Animal Information

Vaccination Acknowledgement*
Has this ESA animal been vaccinated/immunized by a licensed veterinarian
(250 max characters)

Required CTA Animal Documentation:


Service Animal Photo*
No File Chosen
File uploads may not work on some mobile devices.
Upload a photo of your service animal for our records (jpg, jpeg, gif, png, tif, pdf). Max file size is 1MB.
Bill-of-Health*
No File Chosen
File uploads may not work on some mobile devices.
Provide indication from a licensed veterinarian that the CTA animal is healthy (jpg,jpeg,gif,png,bmp,tif,pdf,doc,docx)
Vaccination Record
No File Chosen
File uploads may not work on some mobile devices.
If applicable, provide an up-to-date vaccination/immunization record (jpg,jpeg,gif,png,bmp,tif,pdf,doc,docx)
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