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Parent, Legal Guardian Verification Form

Students under the age of 18 at the time you complete the Housing License Agreement must also have a parent/legal guardian signature

Please complete and return this form to:

Kutztown University

Housing & Dining Services Office

P. O. Box 730 Kutztown PA 19530  

Housing License agreement Signature Form (Fall 2018/Spring 2019) For Students Under the Age of 18 at time of completing the online housing license agreement.    

Student's Name: (first)                                    (last)                                                     

Date of Birth: ____________________________________    

Student ID:___________________________________

Student Signature:                                                                                                       

Parent/Legal Guardian Name (printed): __________________________________________

Parent/Legal Guardian Name (signature):_________________________________________


We have received and read the Housing License Agreement for Fall 2018/Spring 2019.  Our signature indicates that we agree to abide by the terms and conditions of this academic year license agreement and commitment to on-campus housing for Fall 2018 and Spring 2019.   You can fax this to us at 610-683-4038, send it back electronically to, or mail it to us at Housing Office, PO Box 730, Kutztown PA 19530