* First Name:

* Middle Initials:

* Last Name:

* Age:

* Gender:

* City (Permanent Residence):

* State/Country (Permanent Residence):

* Home Phone Number:

* Cell Phone Number:

* Email Address:

* Simmons ID Number:

If on-campus resident, current Hall/Apt and Room:

If on-campus resident, Fall 2009 Hall and Room, if known:

Reason for Applying for Summer Housing:

* Are you a Fall 2009 resident student:

Yes
No

* Current Status (Spring 2009):

Choose One... UG First Year UG Sophmore UG Junior UG Senior Dix Scholar Graduate Student Non-Degree Student

* 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:

» Click to show/hide the Housing Options and Costs

Please select your Length of Stay and Room Option:

Please note rate differences between the length of stay on the housing costs spreadsheet above

5/12-8/30 (full summer) Fall 2009 residents ONLY

5/17-8/30 (full summer) Fall 2009 residents ONLY

5/12-7/1 (Session 1 + spring transition) Spring 2009 residents ONLY

6/30-8/30 (Session 2 + fall transition) Fall 2009 residents ONLY

5/17-7/1 (Session 1)

6/30-8/8 (Session 2)

Other:

Please select your type of room:

Single

Double

Triple (south)

Quad (south)

Please note:

• Students staying between other dates will be charged a weekly rate of $270 for singles or $200 for doubles.

Please note:

• Summer residents applying for a single room will be housed in North or South, according to space availability.
• Summer residents applying for a double room will be housed in South Hall or Mesick Hall.
• Preference for singles will be given to graduate students/Dix Scholars who are continuing residents from the academic year.

* Hall Preference:
Please rank your preferences with first being your most desired.

No Preference

First Choice

Choose One... South Hall North Hall, Floors 4-5 Mesick Hall, floors 1-2 North Hall, Floors 1-3 Mesick Hall, floor 3

Second Choice

Choose One... South Hall North Hall, Floors 4-5 Mesick Hall, floors 1-2 North Hall, Floors 1-3 Mesick Hall, floor 3

If you have Roommate Preference, provide us with names:

Please be sure that they write your name on their applications.

All applicants for doubles must respond to the following questions. Select the response that most closely fits your preference.

On average, I consider myself a...

Choose One... Morning Person Daytime Person Night Owl

Who wakes up / goes to sleep...

Choose One... By 8 am / By 10 pm 8-11 am / 10 pm-1 am After 11 am / After 1 am

I keep my room...

Choose One... Neat Slightly Messy Very Messy

I prefer to study...

Choose One... Outside My Room Quietly With Music, TV, etc.

I prefer to study in...

Choose One... The Library, Lounge, etc. In My Room

A comfortable flow of visitors in my room is...

Choose One... Lots of Visitors Periodic Visitors No Visitors

Although I can't smoke in the building, I smoke cigarettes...

Choose One... Never Sometimes Often

Note: Smoking is not allowed in any room in any residence hall. The College does not offer a smoking lounge or smoking area in any of the residence halls. All people smoking must be at least 50 feet away from the residence halls and not on any walkways.

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.

Additional Comments:

• Medical documentation for a request based on medical needs must be received by Disability Services to determine the necessity of the request.
• 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.

* I have downloaded and read the Summer 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 my contract from the date of sign-in / occupancy as described in this agreement. Cancellation of reservation and changes in residency must be given to the Office of Residence Life in writing at least a week prior to date of cancellation or change.

* 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: