Please fill out and click the
"submit" button.
Entries marked with an * are required fields.
Hendrick
House Status:
Desired Contract Type
*Room Choice:
*Board Choice:
*Contract For:
*Parking:
*Will
you be graduating,
co-oping or marrying at the end of the fall
semester?
Personal Information
*First/MI/Last Name:
/
/
*University ID Number:
*Social Security Number: (000-00-0000)
E-mail Address:
*Phone (000-000-0000):
*Date of Birth (mm/dd/yyyy):
*Gender:
Address
*Home Address:
Apt #
*City/State/Zip:
/
/
Country:
Campus Information
(if applicable)
Address:
Rm #
City/State/Zip:
/
/
Phone (000-000-0000):
Parental Information
*Name of Parent:
*Address:
Apt #
*City/State/Zip:
/
/
Country:
Parent's Occupation:
*Parent's Employer:
*Work Phone (000-000-0000):
We ask for parent employment verification because the parent is a co-signer on this contract.
Emergency Information
*Name of Contact Person: (someone not yet listed, please)
*Contact Person's
Phone: (not home phone, please)
Please
state any medical conditions (allergies, etc) that we should
be aware of:
Please
state any conditions which may require emergency treatment:
Academics
*Year in School:
*Attending School:
College Department:
Major:
Name of High School:
Rank/GPA:
/
Previous College (if
transferring)
Major there:
GPA there:
on a
scale
Roommate Considerations
Roommate Preference:
Must be
mutually requested to be honored
Suitemate Preference:
Must
be mutually requested to be honored
If you do not have a roommate preference, the following information
will help us find a better match.
Extracurricular Activities:
Current Organizations:
Hobbies/Interests:
Political Views:
Religious Preference:
Smoking Preference:
Hendrick House is a non-smoking facility.
Working During School/
Hours
per Week:
/
Special
Medical or Dietary Requirements:
Other
Considerations (Sleeping, Study Habits, Room Temp., etc):
How did
you hear about Hendrick House?
Thank
you for taking the time to fill out this application. By pressing
the button below, you will submit your information to the Hendrick
House office. You will receive a confirmation e-mail shortly.
Note:
This is not a contract. We will contact you to complete the process
