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Break Housing Form

All fields marked with asterisk (*) are required.

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Check one:*

SPRING BREAK ($100.00 per week)

THANKSGIVING BREAK (No charge)

WINTER BREAK ($100.00 per week)

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Name*

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ID*

required e-mail address field

Email address*

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Current Hall*

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Room Number*

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Stay in room?*

Yes

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If staying in a different room, please specify*

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Dates Staying on Campus*

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Reason for stay*

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Cell Phone#*

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I understand that I will be charged $100.00 per week (or any part of a week for this housing) except for Thanksgiving break.*

Yes

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