2020-2021 Break Housing Request Form
Students who need to stay at any time during a break must complete this
form. This form is both for On-Campus Housing and Reinhard Villages
Last Name: _____________________________________ First Name: _________________________________
Current Room/Hall: __________________________________ Student ID#: _____________________________
Student Email: ______________________________________ Cell Phone#: _____________________________
Name of Sponsor (coach/program/employer): _____________________________________________________
Reason for Staying: ___________________________________________________________________________
Please check the appropriate break(s) that you are applying for:
Semester Break:
Nov 20 – Jan 17 (return date is subject to change)
Specific date range(s) staying: ________________________________________________________________
________________________________________________________________
________________________________________________________________
Students who are not required by the university to stay on-campus during the break period will be charged a fee of $50
per night (payable in advance). Students who need to arrive prior to their approved arrival date (but with permission)
will be charged a fee of $50 per night (payable in advance). Please note that this fee covers room only – THE DINING
HALL IS NOT OPEN OVER THE BREAK PERIOD.
NO ONE WILL BE PERMITTED TO STAY WITHOUT PRIOR PERMISSION!
Student Signature: _________________________________________ Date: _______________________
Please download, complete, and then save. Email the completed document
to Residence Life at reslife@clarion.edu by November 19 – Thank you!
Residence Life Services
218 Becht Hall
814-393-2352
reslife@clarion.edu
FOR OFFICE USE ONLY:
Break Assignment: ________________________________________________
Please Type your name in for your signature
