Meal Plan Exemption Request

Dining Services

Albany State University

Meal Plans Coordinator: 229.500.2886

INSTRUCTIONS:

This form is to be completed by the student when he/she wishes to be exempt from the meal plan requirement. Please complete the form ensuring each section contains accurate information. Students who submit false information will be subject to disciplinary action in accordance with the Student Code of Conduct and sanctions which may include suspension from Albany State University. Submit all Meal Plan Exemption Request Forms to mealplans@asurams.edu.

Last Name:

First Name:

Student RAM ID Number:

(If you are Faculty or Staff, please enter your RAM ID #)

ASU Student Email Address:

(If you are Faculty or Staff, please enter your email address)

Please select reason for exemption request (check one):

Dietary Restriction

DIETARY RESTRICTION:

I am requesting exemption from the required Board Plan due to dietary restrictions. A letter and supporting documentation from my licensed medical physician fully describing my dietary circumstances is attached. I understand my request will be reviewed by the food service contractor’s director and nutritionist to determine their ability to provide meals which comply with my restrictions. I further understand that Dining Services will make every effort to comply with my dietary restrictions. In the event they are not able to comply, my request for exemption may be granted. Must attach a letter and supporting documentation from your licensed medical physician for dietary restrictions.

Dietary Restriction

Personal Compelling Circumstances

PERSONAL COMPELLING CIRCUMSTANCES:

I am requesting an exemption from the required Board Plan. A letter which explains the circumstances that preclude my participation in the required meal plan and my supporting documentation are attached. I understand that my request will be reviewed by the Meal Plan Appeals Committee and an exemption may not be granted. I also understand that additional information or documentation supporting my request may be required. Must attach a letter which concisely and fully explains your personal circumstances.

Personal Compelling Circumstances

Your exemption request must include the following:

1. A letter which concisely and fully explains your dietary restriction(s) or personal circumstances.

2. All supporting documentation from your licensed medical physician (for dietary restrictions).

3. Additional documents needed are your current Academic Class Schedule and Official Work Schedule. (if appropriate)

4. Additional documentation you deem appropriate for the Exemption Committee to consider.

Drop your files here

ACCEPTANCE AND ACKNOWLEDGMENT:

TERMS AND CONDITIONS: Students must have submitted a Meal Plan Contract prior to submitting a Meal Plan Exemption request. In order to maintain the integrity of the student account, meal plan charges will be placed on the account and must be paid even if the student has submitted a Meal Plan Exemption request. Should the exemption be granted, the student’s account will be credited the cost of the meal plan or adjusted as recommended by the Meal Plan Exemption Committee.

By signing/typing my name in the box below, I hereby agree that the above listed information is accurate and true information to the best of my knowledge. I understand that all processes for approved removal of my meal plan must be completed in compliance with University polices and procedures.

All personal data and special categories of sensitive personal data collected or processed by Albany State University (ASU) must comply with the ASU Cybersecurity Program Plan, as authorized by the Board of Regents Policy Manual Section 10.4 Cybersecurity:

https://www.usg.edu/policies. Anyone suspecting his or her sensitive personal data has been exposed to unauthorized access, report your suspicion to LegalAffairs@asurams.edu. Otherwise, questions concerning GDPR can be forwarded to LegalAffairs@asurams.edu. By typing/signing my name in the box below and submission of this form/application provides consent to and acknowledgment of the ASU Data Security and Privacy Policy.

Personal Identifiable Information (PII) Consent:

Please check the box below to indicate that you have read and understood the PII policy above.

Personal Identifiable Information (PII) Consent:

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