• Items in bold are required.

    Resident Information

     
     
    For which academic year are you applying for housing?
    First Name
    Middle Name
    Last Name  
    Current Campus Address
     
    Gender

    Class Standing

    Cell Phone
    UC Email Address
    Alternate E-mail Address 
    Do you plan to register an automobile on campus?

     


     

    Lease Information

     
     
    Stay in Current Assignment
    Meal Plan Option
       
    Select Lease Type
    All first semester graduate students will be required to live in four bedroom apartments.
     
    Change Preference 1
    Change Preference 2

    Roommates

    If you have chosen a two-bedroom or four-bedroom apartment, please list your roommate name(s), current address(es), and contact phone number(s). If you are married, list your spouse's name and address (List as "Spouse"). NOTE: Graduate students who wish to live together must list each other as desired roommates in their applications. Applicants must be graduate students (spouses do not need to be graduate students).
    Name(s), Address(es), and phone number(s) of Desired Roommates If you are married, enter your spouse's name, address, and phone number.
     

    Medical Emergency Contact Information

     
     
     
    For the following 3 items, please indicate if you have had your Immunization vaccinations.
    Documentation MUST BE SUBMITTED prior to housing assignments being completed.
    MMR (measles, mumps and rubella)

    Hepatitis B

    Meningococcal meningitis

    Emergency Contact's Name
    Emergency Contact's Relationship
    Emergency Contact's Primary Phone
    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)  
       

    Agreement

    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.