Minor Visitor Request Form by changcheng2


									                  Department of Residence Life
                  1032 W. Sheridan Rd. | Chicago, Illinois 60660
                  p (773) 508-3300 | f (773) 508-3311

Request Form for Minor Visitation in the Residence Halls
The Department of Residence Life strives to develop positive living and learning environments within the residence
halls at Loyola University Chicago. An important part of our role in this involves ensuring the safety of our students
as well as any visitors and guests, particularly those under age 18. For this reason, we request that the following
form be completed for any minor (under age 18) requesting to visit a Loyola University Chicago student in the
residence halls overnight without a parent or guardian. All requests will be reviewed on a case by case basis.

This form must be submitted (via fax, mail, in person, or scanned with signature attached to an e-
mail) no later than 12:00 pm on the business day (Monday – Friday) prior to the minor’s visit to the
residence halls. A Department of Residence Life staff member will contact the student host and/or guest directly
with the decision regarding the request for the minor’s visit.

This form must be completed and signed by the minor’s parent or legal guardian.

Guest’s Information
Minor’s Name:
Minor’s Contact Phone Number (if applicable):
Age:                                              Date of Birth:                    Gender:
Arrival Date/Time:                                                 Departure Date/Time:

Host’s Information
Student Host Name:                                                 Residence Hall/Room #:
Cell Phone Number:                                                 Loyola ID:

Guardian’s Information
Parent or Legal Guardian:
Home Address:
City:                                             State:                            Zip:
Home Phone Number:                                                 Cell Phone Number:
E-Mail:                                                            Work Phone Number:

 By signing this document, I understand that:
         As a guest of Loyola University Chicago, my child is responsible for following all University policies (as
          stated in the Student Handbook) as well as state and federal laws.
         If at any time my child or their student host violates University policy, I understand that I may be contacted
          to pick up my child immediately.
         Submitting this form does not guarantee that permission will be granted for my child to visit Loyola
          University Chicago overnight. The Department of Residence Life reviews requests for overnight visitation
          on a case by case basis.

In consideration of Loyola University Chicago’s allowing my child to visit overnight, I hereby release and hold
harmless Loyola University Chicago, and each and every one of their affiliates and subsidiaries, as well as each of their
trustees, officers, representatives, employees and agents against loss from any and all claims or causes of action for all
known and unknown, foreseen and unseen, bodily injuries, damages to property and consequences thereof which
may be sustained by my child or by me arising out of, or in connection with, my child’s visit. In addition, I agree to
take full responsibility for any damage done to University property by my child during his/her stay at Loyola
University Chicago.

Parent/Guardian Signature: __________________________________                      Date: ______________

                                        Completed forms can be returned:

        In Person:       Department of Residence Life (Simpson LLC, Room 107)
        Faxed:           (773) 508-3311
        Mailed:          Department of Residence Life, 1032 W. Sheridan Rd., Chicago, IL 60660
        E-Mailed:        res-life@luc.edu

 Staff Use Only
 Date/Time Received:                                              Received Via:    Email     Fax      Mail
    Approved       Denied                                         Reviewed By:

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