MSUM Housing Live On Campus Exemption Request Form

* indicates a required field

Do you currently live on campus at MSUM?* Yes No

Current Residents: this exemption form is for incoming students, only prior to the term start. If you would like to apply for Contract Release, please visit the Housing Office in Ballard 120 to review the process and pick up the form.

First Name:*

Last Name:*

Email:*

Dragon ID:*

First semester to attend MSUM:* Spring 2024 Fall 2024 - Spring 2025

Reason for exemption:* I will be living with my parent(s) or legal guardian(s) full-time in their primary residence that is within a 50 mile radius of MSU Moorhead. I will be enrolled fully online for the semester and will be living with my parent/legal guardian at my permanent address. I will be enrolled in 9 or fewer credit hours during BOTH the fall and spring semesters of this academic year. I have primary custody of a minor child. I am married. I will be 21 years or older on the first day of classes of my entering term. I am a transfer from a University/Community College. I require a physical medical accommodation. I require a psychological or mental health medical accommodation. I have extenuating circumstances.

Note:* I understand I am required to submit a letter from my parent/legal guardian with their signature agreeing to these terms and that I will be living at home with them. This letter simply needs to state my parents/legal guardians are acknowledging I am living at home with them. It can be handwritten and a photo snapped of it and emailed to housing@mnstate.edu OR it can be a direct email from the listed parent email.

Note:* Blended/Hybrid is not considered fully online as there are in-person requirements. I understand this is a request for fall semester only and that I must resubmit my request once I have registered for spring semester classes. In addition, I understand I am required to submit a letter from my parent/legal guardian with their signature agreeing to these terms and that I will be living at home with them.

Note:* I understand I am required to submit a letter from my parent/legal guardian with their signature agreeing to these terms and that I will be living at home with them.

Specify University/Community College:*

Note:* For physical health issues, you must provide a brief description in the textbox below, then email housing@mnstate.edu with a written statement describing how MSUM Housing cannot meet your specific accommodation and how living off campus will address your health concerns. Documentation must include written verification on formal letterhead from your personal licensed provider stating the rationale and reason why you cannot live in a residence hall and how living elsewhere mitigates the problem. Letter should include specific details of medical needs and documentation of visits to providers and should be on formal letterhead.

Note:* For personal psychological health issues you must provide a brief description in the textbox below then email housing@mnstate.edu with a written statement describing how your psychological health situation has changed since you signed your current Residence Hall Contract what specific accommodation you need that cannot be met within the MSUM Housing system what MSUM resources you have used to address your concerns and how living off campus will address your psychological health concerns. Documentation should include a letter/information from a mental health counselor psychologist religious counselor or psychiatrist.

Specify Medical Accommodation:*

Specify Circumstances:*

Upload any of the documentation you have for your exemption:

Terms and Conditions* I agree to the First Year Live-On Campus Exemption Policy. The residence hall agreement is in effect for the full academic year. Once a student moves into a residence hall, they are expected to remain on campus for the duration of the contract period. This includes students who are from the local area.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms and Conditions.*

Today's Date and time:*