If you would like to request an exemption from this requirement, please complete this information, check the appropriate box, and provide the necessary documentation as requested. Return the completed form to us.


ID Number:
First name:
Middle Initial:
Last name:
Home Phone Number: ()
Home Address:
Line 1:
City:
State:
Zip:
Email (optional)

Gender
Male
Female

Date of Birth:

Class Standing:
Freshman (0-30 credits earned)
Sophomore (31-60 credits earned)
**Note: Juniors and above do NOT need to complete this form

I am requesting an exemption for:
2006 - 2007
2007 - 2008
2008 - 2009
Reason for exemption:
I live with a parent and commute to campus from within a 40-mile radius of the UW-Whitewater campus.
 I understand that I must commute full-time and may not have a part-time off campus residence elsewhere
(you must complete the commuter form located on this site).
I live with a legal guardian and commute to campus from within the 40-mile radius of the UW-Whitewater campus.
 I understand that I must commute full-time and may not have a part-time off campus residence elsewhere.
(you must provide a copy of guardianship papers with this form and complete the commuter form on located on this site).
I am married (you must provide a copy of your marriage license with this form).
I have my child/children living with me (you must provide a copy of the birth certificate(s) and verification by a third party that the child is living
with you, with this form).
I am a veteran. (you must provide a copy of your discharge papers with this form).
I have enrolled two or more years after my high school graduation.
I have extreme EXTREME circumstances that warrant a special exemption. (please attach specific information and supporting documentation).


Please read this statement carefully before you sign:

I am requesting an exemption to the Board of Regents' policy requiring me to live on-campus during my freshman and sophomore years. If this is granted, I agree to be in compliance with the Board of Regents' policy for the reason(s) stated on the reverse side of this form. I have included the necessary documentation (if any) to support my application for an exemption.

I am aware that knowingly making a false statement, either orally or in writing, to any university employee on a university-related matter is in violation of the UW-System Administrative code and may result in severe disciplinary action that could effect my student status. I further certify that I will remain in compliance throughout this academic year. I understand that if I move from the address listed on the reverse side of this form without written permission from the UW-Whitewater Office of Residence Life, this request will be null and void and that I will be in violation of the UW-System Board of Regents' residency requirement and that the University will take appropriate action.



X______________________________________________________________________________________________________
         Student SignatureDate


If you are commuting from a parent/legal guardian's home, your parent/legal guardian must sign this statement in the presence of a Notary Public, confirming that you are indeed commuting from your parent/legal guardian's home.

I am aware that my signature on this document certifies that the student listed on this form will be living with me in my home on a full-time basis. I am further aware that any false information on this form, or any unauthorized changes in the student's living situation, may result in serious disciplinary action that could affect the student's status at the university.



X______________________________________________________________________________________________________
         Parent/Legal Guardian's SignatureDate

FOR THE NOTARY PUBLIC:

Subscribed and sworn to before me this_____________ day of _________, _______

My commission expires: ____________________________

Notary Signature: _________________________________


Make sure you fill in the appropriate information, sign this form, and send it to:
 Office of Residence Life
Suite 200, Goodhue Hall
Whitewater, WI 53190
Attention: Room Assignments Office