| For which semester are you applying for housing? |
|
| First Name |
|
| Middle Name |
|
Last Name
|
|
| Home Street Address (line 1) |
|
| Home Street Address (line 2) |
|
| City |
|
| State or Province |
|
| ZIP or Postal Code |
|
| Country |
|
| Home Phone |
|
| Cell Phone |
|
| UC E-mail Address |
|
| Alternate E-mail Address |
|
| Date of Birth |
[None]   (Select the Birth Year FIRST from the calendar!) |
| Age |
|
| Gender |
|
The following Immunization requirements are consistent with West Virginia State Law and with the recommendations of the American College Health Association and the Advisory Committee on Immunization Practices. Read more about our Immunization Policy. Download the Immunization form.
Documentation MUST BE SUBMITTED prior to housing assignments being completed.
|
| |
For the following 3 items, please indicate if you have had your Immunization vaccinations. |
MMR (measles, mumps and rubella)
|
|
| Hepatitis B |
|
| Meningococcal meningitis |
|
| |
|
| Status |
|
University Credit Hours Completed
(after current semester) |
|
| Major |
|
| Athletic Teams |
|
Meal Plan Option
First-year students may only select 1,2, or 3.
Upperclassmen may select 1,2,3, or 4.
Only apartment dwellers may select from all 6.
|
|
Rank your preference for room type. Use a 1 for first choice, 2 for second, and 3 for third. First-year students are limited to the first two choices.
|
Brotherton Hall Double
|
|
Middle Hall Double
|
|
Middle Hall Suite
|
|
Middle Hall Apartment
|
|
Ratrie Hall Double
|
|
Ratrie Hall Apartment
|
|
Roommate Name
|
|
Roommate Preference
|
|
| I'd prefer a roommate who is (select one or more): |
|
| I'd prefer a roommate who likes (select one or more): |
|
| My music preferences (select one or more): |
|
| |
Do you plan to register an automobile on campus?
|
|
I need American Disabilities Act (ADA) accommodations.
|
|
APARTMENT AND SUITE INFORMATION: Only groups of four upperclassmen may apply for an apartment or suite. Each member of the group must have at least a 2.85 GPA for the group to eligible. Apartment and suite assignments will be determined by a formula that considers academic class, GPA, judicial standing, and community involvement. Please list one roommate under “Roommate Name” with whom you would like to live in the event that you do not receive an apartment or suite.
|
Apartment/Suite Roommates
|
|
I am a member of (team, organization, group)
|
|
Number of occasions in violation of UC Student Expectations
|
|
Cumulative GPA
|
|
| |
|
All residential students are required to have health insurance while residing on campus. If you are in need of health insurance, please contact the Office of Student Life for information on available plans.
|
Emergency Contact
|
|
Emergency Contact Relationship
|
|
Emergency Contact's Primary Phone Number
|
|
Emergency Contact's Secondary Phone Number
|
|
Health Insurance Company name
|
|
Policy Number
|
|
Group Number
|
|
Health Insurance Company Phone Number
|
|
Primary Care Physician Name
|
|
Primary Care Physician Phone
|
|
List any medical conditions, allergies, and/or medications that the University should be aware of in case of emergency (if none exist, type none)
|
Medical Conditions (if none exist, type none)
|
|
| I agree that checking this box and completing a housing application constitutes an agreement to comply with the terms and conditions of the Housing Contract and the policies and procedures of the University of Charleston. If under the age of 18, a parent or guardian is required to review the Housing Contract and to check this box, constituting an agreement to comply with the terms and conditions found herein. |
|