Valid For: Fall / Spring ________ Date:________________
Student Personal info
Name:_______________________________ ID Number: _______________
Gender: Male / Female Other
Classification: Freshman Sophomore Junior Senior Graduate
Phone Number: (____)_________________________
University Email: _____________________________________________________
Off-Campus Address: _____________________________________________________
_____________________________________________________
Emergency Contact (Parent/ Guardian)
Name: _________________________________ Relationship: ______________
Address:_______________________________________________________________
______________________________________________________________________
Phone Number: (_____)______________________
No Exceptions
Students not meeting one of the 8 criteria MUST seek authorization from the Dean of
Students or Lead Resident Director
Exemption Codes: Code______________
1. Married Student
2. Senior Status (91+ Credit hours)
3. Age (21+)
4. Medical Reasons (Documentation
Required)
5. Single Parent w/ Custody
6. Parent Authorization
7. International Student
8. Local Commuter (Living w/ Parents
or legal guardian in nearby
communities: Xenia,
Wilberforce,Fairborn, Yellow
Springs, Dayton, Cedarville
