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UC-Beckley Housing Application

Before filling out this form:

Items in bold are required. 


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 a Date Delete the Date  (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  

 

Rank your preference for room type.  Use a 1 for first choice and 2 for second..

Hogan Hall Single

  

Hogan Hall Double

  

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. 

  
   

 
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.   
                                           

After clicking "Submit," if you are not taken to a page indicating your application has been received within 10 seconds, then you have not filled in all required fields. Please check your entries and then submit.