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Break Housing Request
  • Break Housing Form

    Required fields are marked with an asterisk.* 

    Layout table for form.
    First Name*
     Last Name*
    Capital ID*
    Cell Phone*
    Residence Hall*
    Residence Hall Room Number*

    Which Break?*
    I plan to:
    Stay until the following date:   [None] Select a Date Delete the Date


    Reason for Request*
    If other, please explain.


    If you are staying to work, employer verification must be turned in by due date of break application for you to be considered. No exceptions.

    I have read and accept the Break Housing Policies & Procedures. The information I have provided on my request is accurate. I have also had an opportunity to ask questions regarding Break Housing, including any questions regarding security risks, reduced staffing, services and facilities. I accept full responsibility and release Capital University from any loss, damage or injury that I may sustain while on campus during break.