Blackburn College Residency Exemption Form

Name*

First Name

Last Name

Student's Cell Phone*

Student's Email*

Birthdate*

Primary address at which you will reside*

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Parent/Guardian (If applicable to reason for exemption)

First Name

Last Name

Parent/Guardian Phone Number

Semester Requesting Exemption

Fall 2024 Spring 2025

Do you still wish to participate in the Work Program?*

Yes No

Reason Requesting Exemption (Check all that apply). Documentation may be required:*

I will be residing in the Carlinville area with my spouse. I will be residing in my parent/guardian’s primary residence within 50 miles of campus. I have completed eight semesters or more on the Blackburn campus. I have previously earned a baccalaureate degree. I have senior standing. I have children who reside with me in my residence. I have a serious medical condition that cannot be accommodated in College housing (will require verification documentation from student’s physician). I will be 21 or older by September 1st for the Fall semester or February 1st for the spring semester.

I certify that the information I have given in this petition and supporting information is true and accurate to the best of my knowledge. I recognize, if approval is granted, that it is based on my residency at the address given on this petition. I understand that permission to live off campus is valid only as long as the reason for the exemption exists. The College reserves the right to revoke permission granted for off-campus residency when the College deems it necessary or appropriate. Your local address and phone number must be maintained through the Records Office in order to remain valid. Page 14 of Blackburn College’s Student Handbook labels “Offenses of Dishonesty” as a violation of the Student Conduct Code and defines the violation as, “Acts of dishonesty including, but not limited to, academic dishonesty; furnishing false information to any College official;forgery, alteration, or misuse of documents or records.” If a student is found in violation of the above policy, judicial action will be taken.

Student's Signature*

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Use your mouse or finger to draw your signature above

Date*