Fillable Housing Agreement Release Form (Page 2 of 2) in pdf

Housing Agreement Release Form

I am making this request to be released from my Housing Agreement for the following

reason(s):

(Check All That Apply)

Graduating at the end of the fall semester (This will be verified.)

Not enrolling at UWA spring semester (This will be verified.)

Enrolling part-time (less than 12 credit hours) (This will be verified)

Participating in a full-time internship or student teaching position, at least ten miles from

Livingston (You must attach proof of internship/student teaching.)

Marriage (You must attach a photocopy of your marriage certificate or license.)

Custodial Parent of Child (You must attach a photocopy of your child’s birth certificate.)

Pregnant (You must attach a doctor’s statement, verifying the pregnancy and estimating the due date.)

Medical (You must attach a written explanation as to how your medical condition has changed since

moving on campus. You must also attach a letter from a medical doctor, confirming your medical

condition and stating specific recommendations regarding housing.

Your doctor must provide an

explanation as to why these housing needs are warranted, based upon your medical condition. The

Housing Office reserves the right to offer a room or building change to meet these needs, if doing so will

meet the medical needs of the student, as stated by the medical professional.

Extreme Change in Financial Situation (You must attach a written explanation as to how your

financial situation has changed since moving on campus. You must include a letter from your parent or

guardian confirming the financial change or you must provide proof of independent student status. You

must also provide a detailed cost comparison of your projected off-campus living expenses and your

living expenses if you remain on campus.)

Other (You must attach an explanation of why you need to move out of the residence halls.) Please be

aware that “I want to get an apartment” and “I don’t like the dorms” are not valid reasons.

I affirm that the information provided on this form and on all attached documents is true. I understand

that providing false information to UWA is a violation of the Code of Student Conduct.

______________________________________________ ________________________

Signature

Date

Please be aware that signing a lease for an off-campus apartment is not a valid reason for being released from

your housing agreement. For this reason, you should not sign a lease for an off-campus apartment until AFTER

you have been released from your housing agreement. If you are not released from your Housing agreement,

you will continue to be charged rent for the entire academic year, even if you move off-campus.

Luther Gremmels, Director of Campus Life and Housing, will send an e-mail to your UWA e-mail address within

five business days, notifying you whether you have been released from your Housing agreement. If released,

you will be charged for housing until the date that you have checked out of your room with your hall director (or

residence life coordinator) and returned your key (if applicable).

RETURN COMPLETED FORM TO THE HOUSING OFFICE - BROCK HALL, ROOM 121

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Housing Agreement Release Form Page 2