Housing Exemption - Bushnell University

Name*

First Last

Student Status*

New/Transfer Student
Returning Student

Phone*

Birthday*

(M/D/YYY)

Permanent Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Bushnell Email*

Reasons Requesting Exemption

I hearby request an exemption from the on-campus residency requirement due to the following reasons: (Please check one box and provide required documents if listed below).

The following exemptions are automatic and do not require approval from the Housing Committee:

I will commute daily from the permanent home of my parent/legal guardian **
I am or will be 21 years or older prior to September 1, 2020
I am married
I am the parent/legal guardian for a dependent child

** Student and parent must complete the Verification of Residency with Parent(s) Waiver

The following exemption requests require approval from the Housing Committee: Medical, Financial, and Special Circumstances.

Medical: This request for exemption must include a letter from the student detailing the circumstances and housing alternative/roommate(s). Also required is a letter from the physician or health care provider with diagnosis of the specific medical condition along with an explanation of how the condition would prohibit adequate functioning in a group living environment or how the condition would be intensified in such an environment.
Financial: This request for exemption must include documentation that you have applied for financial aid, a letter from the student detailing the extreme financial crisis and housing alternative/roommate(s), and also a letter from the parent or legal guardian detailing reasons why they cannot or will not financially support the student with verifiable documents (e.g. FAFSA, tax statement) showing significant financial hardship as well as how this will be a part of the student’s financial solution. Please note: a copy of a rental agreement/lease does not demonstrate a financial need nor document a need for exemption.
Special Circumstances: This request for exemption must include written explanation of the extraordinary circumstances together with documentation of those circumstances and housing alternative/roommate(s). Please note: additional information may be requested by the housing committee.

Please email any additional documentation (i.e.- doctors notes, financial statements, etc.) to the Director of Residence Life at gbrock@bushnell.edu.

Electronic Signatures

I realize that the housing charge will be posted on my account if I am not granted an exemption. I also understand that knowingly making false statements and/or presenting false information to a university official is a direct violation of Bushnell's Student Handbook and disciplinary action will be taken. By signing and submitting this form, I acknowledge that I understand the on-campus housing expectation and attest that the statements and any information which I provide are true and accurate.

*

I, the student have read the above and understand

E-Signature (type name)

Are you under the age of 18?

Yes
No

I, the parent/guardian, have read the above and understand

Parent/Guardian E-Signature (type name)

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Comments

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