Housing & Residence Life
Kieffer Hall Rm 033Phone: (717) 477-1701Fax: (717) 477-4040Email: firstname.lastname@example.org
Address of parent(s)/guardian(s):
Financial: Financial data will be verified with the Financial Aid Office. What has changed in your financial situation
since the time you signed the housing agreement? What is the amount of projected
Employment: Include employer’s name and address below. Explain why you are unable to reside on
campus and perform employment duties. Were
you employed in this job when you signed your housing agreement?
Medical: Send requirements from physician. All medical information shared for
the purpose of being released from the housing agreement needs to be processed
through the Office of Disabilities Services. Explain how living on campus affects your
Family or Personal Support:What has changed in your family or personal situation since the time you
signed the housing agreement? How will residing at home or off-campus resolve
or improve this situation?
Name of Student: First Name: Last Name: Student ID:
Hall: Room#: Email:
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Shippensburg University - 1871 Old Main Drive - Shippensburg, PA 17257 - (717) 477-7447
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