Residential Life Survey

General Information
First Name:
Middle Name :
Last Name:
Preferred Name/
Nickname:
Date of Birth:
Applying for Entry Year:
Entering as a:
   
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
   
Name(s) of Parent(s)/Guardians(s)
Address of Parent(s)/Guardians(s)
High School or Last College Attended
Religious/Denominational Preference
Proposed College Major
Hobbies
Roommate Preference
I would like to request a specific roommate.
Name of desired roommate
Note:  This person must also request you on their application.
I do not have a specific preference.
I request a private room.  Note: Private rooms are based on availability and cost an additional $500.00 per semester.
  I desire a roommate with the following qualities:
  List any special needs you have.
  I am:
Neat or Somewhat messy
  I am a:
Nightowl or Early Bird
 

I would describe myself as:  (select all that apply)
Residential Hall Preference

Samford Hall or North Hall - $2,130/semester
Ingram, Arendall, or Bedsole Hall - $1,945/semester

**Placement will be made based on the gender assigned to each individual residential facility.
Food Service Options - $1,440/semester
Select the meal plan you desire:
19 meals per week including $25.00 flex dollars per semester
15 meals per week including $75.00 flex dollars per semester
10 meals per week including $150.00 flex dollars per semester

Medical Information
Allergies
Medications taken on a regular basis
List any pre-existing health concerns/issues
Please select your hospital preference in the event of a medical emergency:

Insurance Information
Primary Company
Address
Phone #
Primary Cardholder
Group #
Policy #
Effective Date
   
Secondary Company
Address
Phone #
Primary Cardholder
Group #
Policy #
Effective Date

Driver’s Information
Vehicle Make & Model:
Year:
Color:
License Tag #:
License Tag State:
Driver’s License #:
Driver’s License State: