* First Name:

Middle Initials:

* Last Name:

* Age:

* City (Permanent Residence):

* State/Country (Permanent Residence):

* Home Phone Number:

* Cell Phone Number:

* Email Address:

* Simmons ID Number:

Refer to your Admissions Packet or Housing Application email.

* Major(s):

* Enrollment Status (Fall 2008):

Full-time
Part-time

* Class Status (Fall 2008):

Choose One... First Year Sophmore Junior Senior

* Student Status (Fall 2008):
Choose One... First time, First Year Incoming Transfer Current Commuter Current Resident Dix Scholar Returning Resident (LOA, abroad, internship) Special Student / Non-Degree

* Type of Insurance:

College Plan
Private Plan

Insurance Company:

Policy Number:

Subscriber:

Parent / Legal Guardian:

* Name:

* Address:

* Home Phone Number:

* Work Phone Number:

* Cell Phone Number:

* Relationship to you:

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

First year students are encouraged to select either a 19, 14, or 100 meal plan for the first semester. The 10 meal plan may be selected for the second semester.

• The first number denotes the number of meals per week and the second, the number of points (which work like cash) per semester (except in the case of 100 meals per semester).
• Students may change their meal plans during the first week of classes.

* Meal plans:

Choose One... 7 meals / 170 points 10 meals / 130 points 14 meals / 90 points 19 meals / 50 points 100 meals / 150 points

To help us make a good roommate match, it is important that you answer all these questions yourself in a thoughtful and honest manner. Assignments are made on a space available basis and we make every attempt to honor your preferences. Select the response that most closely fits your preference.

* Generally, I consider myself a...

Choose One... Morning person Combination Night owl

* I keep my room...

Choose One... Neat Slightly messy Very messy

* I prefer to study...

Choose One... Outside my room (library etc.) Quietly in my room With music, TV, 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.

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

We offer the option to live in a community with a specific focus. Please read the information on these options provided below and select any that interest you. These housing options are available on a limited basis.

• The Wellness Community (South Hall): South Hall is a community that supports and promotes a healthy, balanced lifestyle, an ongoing process that is different for each individual. Each member of the South Hall community will be asked to respect the Wellness Community substance-free atmosphere.
• Quiet Floor (Simmons Hall): The quiet floor is designed for students who prefer a quiet atmosphere. This floor generally maintains quiet for sixteen hours per day. Floor members decide the specific hours.

If you have Roommate Preference, provide us with names:

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

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 no later than June 9, 2008 to determine the necessity of the request. In spring 2009, current resident students who plan to live on campus for the fall must submit medical documentation no later than March 31, 2009 to determine participation in the Room Selection process.
• 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 Undergraduate 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: