Break Housing Form

Required fields are marked with an asterisk.* 

Layout table for form.

First Name*	Last Name*
Capital ID*	Cell Phone*
Email*
Residence Hall* (Select) College Ave Cotterman Saylor-Ackermann Schaaf SS Capital Commons CU Apts. Sheridan Ave. Trinity Apts Honors House Astor Ave	Residence Hall Room Number*
Which Break?* November Break Winter Break Spring Break Easter Break Extended Stay
I plan to: Stay until the following date:   [None]   OR Stay for the entire break.
Reason for Request* (Select) Baseball Cheerleading Cross Country Football Golf Graduating Senior International Student Men's Basketball Men's Soccer Men's Tennis Off-Campus Job Out of State RA Softball Summer Resident Track Volleyball Woman's Basketball Women's Soccer Women's Tennis Working for University Department Other
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.

|