* First Name:

Middle Initials:

* Last Name:

* Age:

* Date of Birth:

mm/dd/yyyy

* Gender:

* Address (Permanent Residence):

* City (Permanent Residence):

* State/Country (Permanent Residence):

* Home Phone Number:

* Cell Phone Number:

* Email Address:

* Simmons ID Number:

If you are an incoming graduate student, please contact your Program of Study to obtain this number.

Please enter the information below for the term you are applying for housing.

* Term of study:

*Program of Study:

* Enrollment Status:

Full-time
Part-time

* Class Status:

Choose One... Incoming Graduate Student Returning Graduate Student Incoming Dix Scholar Returning Dix Scholar

* Type of Insurance:

College Plan
Private Plan

Insurance Company:

Policy Number:

Subscriber:

* Name:

* Address:

* Home Phone Number:

* Work Phone Number:

* Cell Phone Number:

* Relationship to you:

Note: Please keep all emergency contact information updated on AARC.

Please see the Dining Services page for FAQ on the residential meal plans.

• Students may change their meal plans during the first two weeks of classes.

* Meal plans:

North Hall
South Hall, 5th Floor

North Hall floor preference:

Staying in same room from previous academic year

Please share any additional information about yourself you feel we should know when we make your housing assignment. This may include information about physical, learning, or psychological disabilities. Please note that you do not need to disclose any information on this application, as your special requests will be processed through Disability Services.

• Please visit Disability Services for information and necessary medical documentation forms.
• Send documentation forms to the ADA Compliance Officer: 300 The Fenway, Boston, MA 02115-5898 or email to ada@simmons.edu.

Additional Comments:

* I have downloaded and read the Graduate College Housing License Agreement and will retain it for my files. I understand the terms and conditions contained therein and I agree to them.

* I agree to pay all fees when due, to abide by all rules and regulations as may be established by the College and hall staff within my residence hall and to conform to all College and residence hall policies as stated in the Student Handbook, College Catalog, and other College publications.

* I understand that my signature obligates me financially for the cost of a residence hall space through the end of the academic year from the date of sign-in / occupancy as described in this agreement.

* I understand that I am submitting an application which neither guarantees nor reserves residence. My application will be reviewed to ensure that completeness and eligibility requirements are met.  

By typing my name in the box below, I understand that I am electronically signing this application:

* Signature (type full name):

* Date:

Signature of Parent or Guardian (if resident is under 18 years of age):

By typing my name in the box below, I understand that I am electronically signing this application:

Signature (type full name):

Date: