Housing Cancellation Waiver Form

Purpose: This form is to collect data from the student about a cancellation or housing charge appeal. The information to be collected is, first/last name, A#, date of the appeal, reason for the appeal, supporting evidence(photos/documentation) what they want out of the process. This will allow the review committee to be able to look at the supporting information in an organized fashion.


An Islander experiencing extenuating circumstances that warrant consideration of a refund. If you believe your situation should be reviewed, please provide the following information. Once your information is received, it will be forwarded to the Assistant Director of Student Operations.

What is the students first name?

What is the students last name?

Only include numbers for this field

All communications will be sent to the student's Islander email address.

What term are you appealing charges from?*

Please select one

What is the cancellation amount?*

Please Note:­ This is not a comprehensive list of documentation examples. Students should consider their situation and provide supporting documentation that speaks specifically of the extenuating circumstance(s) they have noted as the basis of their appeal.

Appeals due to illness or injury

If you engaged in the Withdrawal with Extenuating Circumstances process, your appeal request should include a copy of the Health Evaluation Form completed by the student’s licensed health professional. Appeal requests not related to a withdrawal should include supporting medical documentation that speaks directly to the circumstances and dates of impact and should be on official medical letterhead.

Appeals due to illness or injury of immediate family member

The appeal request must include a letter from a medical professional confirming the situation, dates of impact, and the student’s role as caregiver. Documentation should be on the official medical letterhead.

Appeals due to the death of an immediate family member

The appeal request must include official documentation of death (i.e., death certificate or obituary) and the student’s relationship to the deceased.

Appeals due to non-attendance (never attended)

The appeal request must include verification of non-attendance from the instructor (non-attendance due to extenuating circumstances).

Appeals due to university error/Student error

The appeal request must include confirmation of the error's nature/circumstances which prevented the student from dropping the class in a timely fashion.

Please upload any supporting documentation*

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