Residence Requirement Waiver Commuter Request
Office of Student Life at Emory & Henry College • P.O. Box 947, Emory, VA 24327 ✆ 276-944-6529
Email address
For students who live off campus and commute to the college for classes.
This is to certify that I, the undersigned below, will be residing at the home of my parents, guardian or spouse and commuting to Emory & Henry for the term or school yea). I understand that if I do not reside at this address during the time stated above, my housing agreement with the Student Life Office will be reinstated and I will be financially responsible for campus housing.
Student Name
Your answer
Student ID #
Your answer
I will be residing at the following address
Your answer
Phone Number
Your answer
Additional Signatures

I certify that the information provided is true and accurate and the above named student will be residing with me at the address provided.
Parent/Guardian/Spouse Signature*
Your answer
Date*
MM
/
DD
/
YYYY
Parent/Guardian/Spouse Phone Number
Your answer
* By typing your name and date, you are confirming the above information is accurate and correct and approved for use by the name owner, and will function as a legal and binding signature once submitted with your form.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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