Office of Housing and Residence Lifeexemption Form

CLARK ATLANTA UNIVERSITY

OFFICE OF HOUSING AND RESIDENCE LIFEEXEMPTION FORM

(PLEASE PRINT)

Section One – Demographic Information

Select appropriate response:

____ [Fall 20 __ Semester only]____ [Spring 20 __ Semester only]____ [Academic Year 20 __ -__]

Student Name______

900# ______Classification ______Date of Birth ______

Name of Parent(s) or Guardian(s) ______

Phone Numbers: Home ______Cell ______

CAU Email Address:

Section Two –Complete this section if you are requesting to be exempt from the On-Campus Housing policy or for both the On-Campus Housing policy and the CAU Meal Plan policy and select the appropriate reason.

___ Housing Onlyor____ Housing and Meals

I live in the metro Atlanta area with my parent(s). Which County: ___ Fulton ___Cobb ___DeKalb ___Gwinnett ___Clayton County (Must provide a utility bill as proof of residency and statement from parent or guardian)

 I have children or dependents for whose care I am responsible. (Provide copy of birth certificate or court order supporting guardianship)

 I am married or involved in a domestic partnership where we share a permanent residence. (Provide copy of marriage certificate or notarized letter supporting shared residence)

 I have a medical condition or I am a caregiver of someone with a medical condition that requires special living accommodations. (Must provide medical documentation)

 I will be 24+ years of age before August 1. (Must provide a copy of a birth certificate or driver’s license)

(If none of these reasons apply, please write a detailed statement of your situation on the back on this form.)

Section Three –Complete this section if you are requesting to be exempt from the CAU Meal Plan policy only.

____ Meal Plan Only

 I have a medical condition or I am a caregiver of someone with a medical condition that requires special living accommodations. (Must provide medical documentation).

(If it is not a medical reason, please write a detailed statement of your situation on the back on this form.)

My signature indicates that I understand that the Director of Housing and Residence Life or designee must receive the Exemption form and all supporting documentation no later than August 1 for Fall and December 15 for Spring. It also indicates that I understand that failure to complete the on-campus housing requirement or providing false or misleading information to the Department of Housing and Residence Life to receive an exemption from the on campus housing requirement may result in cancellation of registration privileges and/or revocation of acceptance to Clark Atlanta University.

______

Student SignatureDate

______

Parent/Guardian/Guarantor Signature (if student is under 18 years of age)Date

*YOU MUST PROVIDE DOCUMENTATION WITH YOUR EXEMPTION FORM*

**APPROVAL OF AN EXEMPTION REQUEST DOES NOT AUTOMATICALLY CANCEL OR RELEASE YOU FROM YOUR CONTRACTUAL OBLIGATIONS. YOU MAY BE REQUIRED TO PAY A BREAK THE AGREEMENT OR LEASE FEE.**