Break Occupancy Form

ITHACA COLLEGE | Office of Residential Life

I declare and understand that by providing valid Ithaca College Student ID numbers with this BREAK OCCUPANCY FORM, that ...

all residents and occupant(s) of the room, suite or apartment have thoroughly read and agree to comply with the Recess Housing requirements disclosed on this web site and the Break Closing Notice appropriate to the occupancy period being requested, and have granted permission to all non-resident student occupant(s) listed to reside within the room, suite or apartment indicated.
each Break occupant indicated is designated exclusive use of the resident's bed who submitted this form for the dates requested.
an E-mail will be sent to your Ithaca College E-mail address detailing the approval or denial of this request.

1. Select Your Building: 2. Enter Your Room, Suite or Apartment # (with bedroom letter for Apartments & Suites):

Name

Student ID #

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

3. Current Resident:
(supply your name and ID number even if
staying for any portion of the break)

you are not

4. Check dates you will be in your room during the break:					11/21	11/22
11/23	11/24	11/25	11/26	11/27	11/28

5. Non-Resident Occupant:
(supply the name and ID number of any student other
will stay in place of you in your room for any portion

than you who
of the break)

6. Check dates student will be in room during the break:					11/21	11/22
11/23	11/24	11/25	11/26	11/27	11/28

7. Additional Occupant:
(supply the name and ID number of any additional
will stay in place of you in your room for any portion

student who
of the break)

8. Check dates student will be in room during the break:					11/21	11/22
11/23	11/24	11/25	11/26	11/27	11/28

By submitting this form, I acknowledge that I have thoroughly read and understood the information disclosed above.

Updated: Wednesday, September 2, 2009 | Residential Life Web Administrator, Linda Koenig (lkoenig@ithaca.edu)