Housing Appeal Form

Full Legal Name

Address

City

State

ZIP

Phone

Are you a

New StudentCurrent Student

Age

Gender

Date of Birth

Student ID

Current College Class Status

Year of High School Graduation

Cumulative GPA

Total Completed Credit Hours

Release Requested for

Parent's Name

Parent's Address

City

State

ZIP

Parent's Email

Parent's Phone

Marriage Information

Date of Marriage

Commuter Information

Full name of person with whom I intend to live

Address I intend to commute from daily

Relationship

Relative's Phone:

Please fill out the following commuter exemption form and upload it below: COMMUTER-EXEMPTION-FORM.pdf

Upload Commuter Exemption Form

Financial Hardship Information

Financial Situation

Do you expect to be employed during the school year?

If yes, hours per week:

If no, reasons for not working:

Physical/Mental Health Information

Please print the following medical exemption form and fill it out MEDICAL-EXEMPTION-FORM.pdf

Other

Please Explain:

How/why would living off-campus enable you to be a more successful student - academically, personally, and socially?

I acknowledge by my signature that I have read the preceding Housing Contract Exemption and Appeal Process. I further acknowledge that the information I have provided is accurate for the semester/academic year for which I am requesting this release. I understand that this release is not approved until I receive a written release from the Residence Life Office.

I acknowledge that semester room charges will be applied if I have not been approved for a release from the South Dakota Board of Regents Residency Requirement. I further acknowledge that charges will also be applied if I make a false claim to be living at home with parent or legal guardian and it is later determined that I am not living at the stated location. I am also aware that it is a violation of the Student Conduct Code to present false or misleading information.

Student Signature

Date

Parent Signature

Date