| For which semester are you applying for housing? |
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| First Name |
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| Middle Name |
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Last Name
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| Current Campus Address |
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| Cell Phone |
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| E-mail Address |
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| Alternate E-mail Address |
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| Gender |
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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.
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For the following 3 items, please indicate if you have had your Immunization vaccinations. |
MMR (measles, mumps and rubella)
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| Hepatitis B |
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| Meningococcal meningitis |
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| Emergency Contact's Name |
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| Emergency Contact's Relationship |
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| Emergency Contact's Primary Phone |
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Health Insurance Company name
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Policy Number
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Group Number
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Health Insurance Company Phone Number
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Primary Care Physician Name
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Primary Care Physician Phone
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List any medical conditions, allergies, and/or medications that the University should be aware of in case of emergency (if none exist, type none)
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Medical Conditions (if none exist, type none)
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| Student Status for 2013-2014 academic year |
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| Select Lease Type |
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| Select an Option
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Efficiency Apartment (1 person)
One-Bedroom Apartment or Married Apartment
Two-Bedroom Apartment (2 persons)
Four-Bedroom Apartment (4 persons)
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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.
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| Do you plan to register an automobile on campus? |
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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).
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Name(s), Address(es), and phone number(s) of Desired Roommates
If you are married, enter your spouse's name, address, and phone number.
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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.
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