Student Housing Cleaning Refusal Form
Use this form to formally refuse scheduled cleaning service for your student housing unit. Please complete all fields to ensure your request is processed.
Full Name
*
First Name
Last Name
Student ID Number
*
Housing Unit or Room Number
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date(s) Cleaning is Being Refused
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Refusal
*
Please Select
Illness/Quarantine
Personal Preference
Schedule Conflict
Recent Cleaning Already Performed
Other
If you selected 'Other', please specify your reason
Special Instructions or Notes for Housing Staff
Acknowledgment: I understand that by refusing scheduled cleaning, I am responsible for maintaining the cleanliness of my housing unit and any resulting conditions.
*
I acknowledge and accept responsibility
Date of Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Refusal
Should be Empty: