Housing Release Request

Required fields are marked with an asterisk.*

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To ensure accuracy of contact information and to allow for changes in eligibility, students will be asked to complete the Release from Housing Request process annually. As long as none of the eligibility requirements are being changed, students will not need to reproduce documentation.
Application Type* New Application Renewal

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First Name*	Last Name*
Permanent Address	City
State	ZIP
Phone	Email*
Student ID Number*	Current Status
Current Residence Hall (if applicable):	Room Number:

If approved to live off campus you will need to provide your off-campus contact information where you will be residing during the academic year. This information is required for emergency contact and general University communications.
Off-Campus Address:	City:
State:	Zip:
Off-Campus Housing Eligibility Requirements - Please select one or more of the requirements below. Your selections will be used as the basis for evaluating your request. (Check all boxes that apply)
Age 22 or above Complete 60 credit hours by next semester Married (you are required to submit a copy of your marriage certificate) Live with parents/court appointed guardians in permanent residency within 30 miles of campus Special Accommodations Extenuating circumstances
Please note, the 30 mile requirement for release becomes effective with students entering Capital University Fall 2012 semester.

Emergency Contacts

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Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship

Please provide a confidential contact person to be notified within 24-hours of a determination that the student is missing as established by campus safety or local law enforcement. If the student is under the age of 18, the students parent/guardian will be notified.

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Use Emergency Contact
Missing Person Contact Name
Missing Person Contact Phone
Missing Person Contact Relationship

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I attest that the information provided is accurate. I understand that it is a violation of the Student Code of Conduct to submit false or materially misleading information to Capital University personnel. I Agree