Utica College Residence Life Release Application
All students are required to live in a Utica College residence hall for the first two years of attending Utica College, except in any of the following situations:
•You are residing at home with your parents or legal guardians, who live within a 30 mile radius of campus
•You are a transfer student, who lived on campus for two years at another institution
•You will be 21 years of age by August 1st.
In order to apply for a release from the residence hall requirement, you must complete this application. Please note the following additional criteria needed to qualify for a release.
Name *
Your answer
Student ID Number *
Your answer
Current Room Assignment *
Your answer
Current Class Year *
Your answer
Semester Applying For Release *
Your answer
Cell Phone Number *
Your answer
I'm applying to be released because I am Studying Abroad. *
You must provide documentation, indicating the term you will be studying abroad, along with a copy of this Release Application to the Office of Student Living and College Engagement.
I am applying to be released because of Financial Reasons. *
In addition to this Release Application, you must: 1. Discuss your financial concerns with your Student Financial Services (SFS) Counselor. 2. Have exhausted all available payment options with SFS. 3. Provide third party documentation to SFS that a legitimate financial change has occurred since you moved in. An example of third party documentation is a letter from an employer (on business letterhead) stating a loss of a job. Once the above steps are completed, SFS will provide a recommendation to the Executive Director of Student Living and College Engagement within five (5) business days. Completion of the Office of Student Living and College Engagement Release Application and associated criteria does not guarantee a release from your housing requirement.
I am applying to be released because of Medical/Psychological reason *
Medical / Psychological releases are rarely granted, so please plan accordingly. In addition to this Release Application, you must provide a typed letter, on letterhead, from your Primary Care Physician (PCP) or clinician managing your medical / psychological concern. The letter must include: •The diagnosis. •Current treatment. • Length of time the condition has been treated by the professional providing the letter. •Anticipated benefit and related rationale on how the release will improve the condition. The letter should be provided to the Executive Director of Student Living and College Engagement. If you are not comfortable with your information going to Student Living and College Engagement, you may provide it to the Director of the Health Center or Director of Counseling. Once the information is collected, Residence Life will consult with the Health Center/Counseling Center before making a decision.
I agree that all the information I have provided in this form is truthful and I agree to sending all information that is needed to assist in this process. I also understand that by filling out this form, I am not released from housing until I have received confirmation from the Director of Residence life. *
Never submit passwords through Google Forms.
This form was created inside of Utica College. Report Abuse - Terms of Service - Additional Terms