Housing Application | Kuyper College

Semester

Fall Winter

Year

Name (last, first)

Address

City

State/Province

Zip Code

Email Address

Phone Number

Gender

Female Male

Date of Birth (MM/DD/YYYY)

Anticipated Year at Kuyper (Please check one)

Freshman Sophomore Junior Senior

Initial Living Area Preference

Residence Hall Apartments (Students 21 or older with junior or senior status)

Meal Plan Choice (required for on-campus residence)

20 meals per week 15 meals per week 10 meals per week 5 meals per week (juniors and seniors only)

Please answer the following questions honestly. This information is used to match you with a roommate.

Please rate yourself in the following areas: (1=very true of me; 5=not at all true of me)

Cleanliness is important to me:

1 2 3 4 5

Sports/Exercise is important to me:

1 2 3 4 5

My studies are important to me:

1 2 3 4 5

My faith is important to me:

1 2 3 4 5

Involvement on campus is important to me:

1 2 3 4 5

My preferred study environment is:

Quiet Some noise (music or TV on softly) With music and/or TV on

I would consider myself to be a:

Morning Person (up before 8am) Average Night Owl (to bed after midnight)

I would like a roommate who is:

Outgoing/Extrovert Shy/Introvert Somewhere in the middle

How involved do you plan to be on campus?

Very involved Somewhat involved Not very involved

How involved would you like your roommate to be?

Very involved Somewhat involved Not very involved

Do you smoke?

Yes No

Would you be willing to room with someone who smokes?

Yes No

I like to listen to music:

Soft Medium Loud

How many hours a week do you spend playing video games?

Less than 5 hours 5 - 15 hours 15+ hours

How many hours a day do you spend on Facebook?

Less than 2 hours 2 - 5 hours 5+ hours

Do you plan on working?

Yes No

If so, how many hours?

Some of my extracurricular activities include:

I would like to name my roommate. (They must also indicate the same on their application.)

Any additional information (medical conditions/accommodations, allergies, counseling issues, or other things) you feel would be helpful to us in selecting a roommate for you? Please explain and provide pertinent documentation:

I agree to pay Kuyper College all current applicable room/board/deposit housing charges. I agree to abide by student regulations and policies published in the Student Handbook and other college statements. I recognize that I am required to live in Campus Housing my first and second years at Kuyper College unless I am 21 years old, have junior or senior status, live with immediate family or have received special permission from the Director of Student Life

I hereby certify that the facts set forth in this document are true and complete to the best of my knowledge, and I understand that any falsified statements on this document shall be considered sufficient cause for denial or termination of residency.

Student's Signature

Date

Parent's/Guardian's Signature (if student is under 18)

Date

Typing your name in the signature space is used to authenticate your identity as the signer of this document.

THIS CONTRACT IS INVALID IF UNSIGNED.