Student Interim Housing Form

Admissions & Financial Aid

Academics

Alumni

Athletics

Office of the President

News & Events

Student Life

Support the Mount


	Forms

		Housing

		FAQs

		Code of Conduct

		Important Dates

		Services

		What's New

		Staff

		Dean of Students


		Prospective Students
		Graduate and Continuing Studies
		Alumni
		Current Students
		Class of 2013
		Parents
		Media
		Friends and Donors
		Visitors and Neighbors
		Grotto of Lourdes
		Seminary
		Faculty, Staff, HR
		Inclement Weather Policy

Interim Housing Request Form
(Resident Students Only)

Directions: Please fill out this form to request interim housing during break periods when the college is closed or to move in early. For Thanksgiving Break, this form with requests must be submitted by November 16, 2009. Any requests made after the deadline will not be approved.

Resident Student(s) requesting for interim housing during a break period:

For the reason for request field, please type the reason you need to stay on campus over the indicated break period.

First Name*

Last Name*

M.I.

Break Period*

Please type your MSM Email address in the box. Your email address is:
first letter of your first name middle initial then last name@email.msmary.edu
For example - wdthomas@email.msmary.edu

MSM Email Address*

Reason for Request*

Building *

Room Number and Bedroom Letter*

Dates Requested*

Please put dates requesting to stay in this format:
11/24-11/29

READ THE 9 STATEMENTS LISTED BELOW
AND CHECK THAT YOU UNDERSTAND AND AGREE TO THEM

I certify that the information listed above is correct and fully accurate. *

I understand that by submitting this request, I am not approved for interim housing during the indicated break period, and that I will be notified by Residence Life whether I am approved or not.*

In consideration that I am being permitted to occupy University residence halls during all or a part of an interim period, I hereby assume all responsibility for the safety of my person and property during this period, and release Mount Saint Mary’s University, its officers, agents and employees from any liability on account of loss, theft, injury or destruction to myself or property arising in connection with the above described occupancy, and hold Mount Saint Mary’s University, its officers, agents and employees blameless for any and all loss which may arise.*

PERSONAL SAFETY: I understand that it is vital to my personal safety that I observe “common sense” safety precautions during the interim housing period because of the reduced activity and occupancy levels in the buildings and across campus. I agree to keep my room door locked and my keys and Mount ID in my possession at all times. I agree to pull every door closed behind me when I enter or exit my building.*

NO GUESTS: I understand that I may not entertain guests, conduct parties, nor allow other students to live with me during this interim housing period. I understand that violations of this policy could result in disciplinary and/or administrative action.*

MAINTENANCE & CLEANING ACTIVITIES: I understand that University staff will be at work in the residence halls during part or all of the interim period. I understand that my floor, room, apartment, or suite may be entered for inspection, maintenance, cleaning at any time during the interim period by University staff.*

EMERGENCY SERVICES: I understand and agree to report suspicious or unusual activity, the presence of unauthorized persons, disruption of security/safety services or equipment, or any other situation which concerns me, to Public Safety (301-447-5357).*

FIRE: I agree to call 8111 in the event of fire or other emergency to report it immediately. I understand that sounding the building fire alarm will not summon emergency personnel. In the event of fire and I am prevented from leaving through a safe, approved exit, I should move safely to a bathroom window or stairwell window or throw or wave some object from the window that will alert rescuers to my whereabouts.*

I have read, understand, and agree to abide during this occupancy period by all terms and conditions of the University and residence hall rules and regulations outlined in the Code of Student Conduct and Community Standards, which can be reviewed at www.msmary.edu/studentconduct , and those additional terms and conditions set forth below.*

Type your full name as your eletrconic signature indicating you have read, understand and agree to the terms above.

Full Name*