Break Housing Request Form

First Name:		Last Name:
Capital ID Number:		CU Box Number:
Cell Number:		Email Address:

Please select your residence hall:
College Ave	Cotterman	Saylor-Ackermann	Schaaf	SS	Cap Commons	CU Apts	Sheridan Ave.
Room Number:

For which break are you requesting to stay?
November Break	Winter Break	Spring Break	Easter Break	Extended Stay

What is your reason for requesting housing in the residence halls during break?
Baseball	Cheerleading	Cross Country	Football	Golf
International Student	Men's Basketball	Men's Soccer	Men's Tennis	Off-Campus Job
Out of State	Softball	Track	Volleyball	Women's Basketball
Women's Soccer	Women's Tennis	Working for University Department	Other

If you chose other, please list the reason:

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.