Revision:
Commuter Residenal Informaon and Applicaon Agreement:
The student applying for Commuter status MUST meet one of the criteria described at the top this form, have met with the Financial Aid
department, and have been approved by the Director of Residence Life. ***By signing this form you agree with the terms menoned above.
Please provide the address and two contact numbers for the locaon/residence you will be commung from.
Street: Email:
Town: Current Vehicle & License #:
State: Zip Code: Chowan Vehicle Registraon #:
Contact #:
I understand that, all motor vehicles operated by Chowan University Students
Must be Registered by the Department of Public Safety. (Inial Here )
Alternate Contact #:
Student’s Signature (If under 18 Parent/Guardian’s signature)__________________________________________________
COM M UT E R A P P LIC AT ION
** PLEASE READ THE FOLLOWING GUIDELINES BEFORE COMPLETING THIS APPLICATION **
Full-Time students MUST meet one of the following criteria to be eligible for commuter status:
A. The student must be:
Married
A Veteran
Or 23 years of age or older
B. The student must be living with a member
of his/her immediate family within a 40
mile radius of the University.
C. The student must have:
A Junior or Senior rank (60+ credits)
A GPA of 2.75 or greater
A good campus behavior record
You MUST meet with Financial Aid to check the status of your Financial Aid Eligibility:
*** Your residenal status may aect the amount of nancial aid you receive for the academic year. Students who change from a resident to a
commuter may have their university administered funds adjusted if they elect to live o campus. Students must meet with the Oce of
Financial Aid to discuss these changes.***
Student Informaon
Name: Permanent Address
ID: Street:
Date of Birth: Age: Town:
Marital Status:
Single Married Separated/ Divorced
State: Zip Code:
Class Status: Freshman Sophomore Junior Senior
Home Phone #:
Student Status: New Returning (current student)
Alternate Contact #:
Commuter Status Applying For & Eligibility Requirements:
Please Select One of the Following
A. Married, Veteran, or 23 yrs of age or older B. Living with immediate family within 40 mile radius
C. Junior /Senior, GPA 2.75
+
, clean campus behavior record (COMPLETE THE REQUIRED INFORMATION BELOW)
Current GPA: Total Credits RCVD: Disciplinary Record: _
Registrar Sta Signature: ______________________________ Student Aairs Sta Signature: _______________________
Financial Aid Requirements:
The student has met with the Oce of Financial Aid and discussed the adjustments to the awarded aid for the academic year he/she has applied to commute. The
student has been informed of the eect commuter status will have on his/her nancial aid eligibility.
Financial Aid Sta Signature:
Semester Yr. 20
APPROVED: Yes No Sta Signature: Date / /
PHOTO RELEASE
Photographs or recordings may be taken by the university or its designees in public areas of the Chowan University campus and regional centers and at university events. The university may use
such photographs or recordings to document, promote, or provide information about the university and its programs without prior consent by individuals depicted or recorded in them. Public areas
include but are not limited to outdoor areas, classrooms, laboratories, library, athletic facilities, residence hall common areas, dinning and gathering facilities, meeting rooms, and performance
spaces. A student has the right to refuse to permit the release of any or all directory information, and/or the use of her/his image or voice (if clearly identifiable in photograph or recording), without
the student’s prior written consent. Any refusal must be received in writing by the registrar prior to the end of the second week of the academic year, and designate the information not to be re-
leased.. (Inial Here )
Athlec Grant in Aid (AGIA):
Student Athletes that receive Athlec Grant in Aid funds are required to live on campus. These funds are also not permied to pay for private
rooms. Athlec Administraon (not coach) signature indicates that student does not fall under the AGIA requirement to live on campus.
Are you a student athlete? ___ Yes ___ No If yes, Athlec Administraon Signature: _________________________________
Name: ________________________________________
Address: ______________________________________
______________________________________
Relationship to Student:__________________________
Authorization to Release Information (FERPA RELEASE)
Students Name (Print Name)
First__________________________ Middle_________________ Last________________________________
In accordance with the Family Educational and Privacy Act o f1974 (FERPA), I , the undersigned, hereby authorize Chowan University to Release the
following information from my educational record:
1. Student Conduct Information
2. Grades
3. Academic Standing
If you wish for information to be released, please list those name(s) below.
I understand that (1) I have the right not to consent to the release of my educational records; (2) I have the right to receive a copy of such records
upon request; (3) and that this consent shall remain in effect until I revoked by me in writing, and delivered to the Department of Student Affairs
at Chowan University.
Signed this _______ day of ______________________, 201____.
Date Month Year
_____________________________________________________
Signature of Student
Name: ________________________________________
Address: ______________________________________
______________________________________
Relationship to Student:__________________________
Name: ________________________________________
Address: ______________________________________
______________________________________
Relationship to Student:__________________________
Name: ________________________________________
Address: ______________________________________
______________________________________
Relationship to Student:__________________________
Emergency Contact Information:
Father/Guardian Information
Name:_______________________________________________ Preferred Phone Number: ______________________________
First Last MI
Home Phone Number:____________________________________ Work Phone Number:_________________________________
Address (If different from above):______________________________________________________________________________
Mother/Guardian Information
Name:_______________________________________________ Preferred Phone Number: ______________________________
First Last MI
Home Phone Number:____________________________________ Work Phone Number:_________________________________
Address (If different from above):______________________________________________________________________________