Name:

Today's Date:

Campus Box:

Current Hall/Room:

Phone Number:

Reason for Request:

International/Long Distance
Athletics (specify sport)
Student Teaching
Academic Internship
Teacher Assisting
Other (please explain)

Dates Housing is Needed:

This application needs to be completed one week prior to the beginning of the break period. Applications are not considered approved until signed by the Director of Residence Life. A fee for housing of $15 per night may be charged and added to the student's account.