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for Students Experiencing Homelessness
INFORMATION AND ELIGIBILITY CRITERIA
In accordance with statute 1009.25 (1)(f), students who lack a fixed residence are eligible to receive a waiver for their tuition.
Students must provide a letter from a recognized agency which clearly states that he/she is currently experiencing
homelessness. The letter must also confirm that the person is living in a temporary residence or a public or private place not
designed for, or ordinarily used as, a regular sleeping accommodation for human beings. The agency’s letterhead, phone
number, address and the name of the person making the referral must be on the letter and legible. The document must also
have the date the person started receiving services from the agency and the signature of the official making the referral.
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APPLICATION (TO BE COMPLETED BY STUDENT)
Instructions: Students who meet the eligibility criteria above and wish to apply for the fee exemption must complete
the entire section below and submit it to the Admissions and Registration Office.
Student’s Last Name First Name Middle
_______________________________ □ Fall □ Spring □ Summer
MDID
Term
Year
Telephone Number
_______________________________@ ________________._________
Email address
Date of Birth
By signing this form, I (the student whose name and information appears on this application) understand and agree to the
following terms:
a) I must complete this application every term and submit it to the Admissions and Registration Office along with all
required documentation,
Student’s Signature Date Signed
THIS SECTION IS FOR OFFICE USE ONLY:
Processed by (printed name): ____________________________________________ Date: ______________________
Employee’s Signature
Term waiver applied: [ ] Fall __________
[ ] Spring ____________
[ ] Summer __________
Student notified on Date: __________________by: [ ] Telephone
[ ] Email [ ] Letter
A&R Form
Updated 08/2020
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