Housing Requirement Release Form - Spring 2011

Request for Housing Requirement Release Form
Spring 2012

Last Name *

First Name *

ID Number *

Gender *

Male

Female

Current Residence *

Room Number

(Please include Apartment / Townhouse number if applicable.)

Current Phone Number *

###

####

Reason for Request to be released from the Residency Requirement *

Withdrawal from the College

Transfer to another College or University

Graduation

Study Abroad

Active Military Duty

Marriage

Medical/psychological condition*

Demonstrable, non-replaceable loss of support base**

Other***

*: To be reviewed for consideration, you must submit an official letter from your medical provider to the Knight Connections Desk, Todd Wehr Hall, by December 9, 2011; 4:30 PM)

**: To be reviewed for consideration you must submit official documentation outlining the change (unexpected and/or substantial) in your financial situation to the Knight Connections Desk, Todd Wehr Hall, by December 9, 2011, 4:30 PM. Releases are usually not granted for this reason unless they are extreme cases.

***: Please describe below. Also, submit detailed written statement and official documentation to the Knight Connections Desk, Todd Wehr Hall, by December 9, 2011, 4:30 PM.

If Other, please explain:

Electronic Signature *

By submitting this form, I am requesting to be released from the Residency Requirement.

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Department of Residential Education and Housing

Phone: (920) 403-3360
Fax: (920) 403-3361
E-mail: housing@snc.edu

St. Norbert College • 100 Grant Street • De Pere, WI 54115-2099 • 920-337-3181