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Break Housing Form

All fields marked with asterisk (*) are required.

required checkbox field

Check one:*

THANKSGIVING BREAK N/C

WINTER BREAK

SPRING BREAK N/C

SUMMER BREAK

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Name*

required text field

ID*

required e-mail address field

Email address*

required text field

Current Hall*

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Room Number*

required radio button field

Will stay in my room*

Yes

text field

If No, please specify

radio button field

Entire Break, I will be staying on campus.

Yes

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Stay Late – list departure from campus date*

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Return Early – list date returning to campus*

required textarea field

Reason for Staying Late, Returning Early or Staying entire break*

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If you would like to speak with someone from Residence Life regarding this break, please list a cell phone number to contact you

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I UNDERSTAND I MAY BE SUBJECT TO A $100 PER WEEK FEE BASED ON A CASE BY CASE BASIS. **International and Exchange Students will not be charged.

Yes

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Type Full Name to Serve as Signature.

Link (required)