Third Party Release of Cap and Gown Form
Student Name: _______________________________________________________________________
Student ID Number: ___________________________________________________________________
Student Height: ________
Student Weight:
Complete and sign the Limited Release
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Limited Release
I hereby authorize Benedictine University to release my cap and gown to the following person:
Name: ______________________________________________Relationship______________________
Address: ____________________________________________________________________________
I understand that this authorization is only valid for picking up my cap and gown.
Designated person must present a valid form of identity (example: driver’s license, school ID) for the
release of the cap and gown.
Student Signature: ____________________________________________________________________
Date: _______________________________________________________________________________
Submit Completed Form to Donna Madia, Scholl Hall, Room 155.
Fax: 630-829-6369 or email at dmadia@ben.edu
Form may also be presented on day of pick up.
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