New Student Housing Application for Living Learning Centers Academic Year

Transcription

1 New Student Housing Application for Living Learning Centers Academic Year Fisk University Office of Residence Life & Campus Services Office (615) Fax (615) PLEASE PRINT LEGIBLY OR TYPE FOR OFFICE USE ONLY Received Date: Time Bldg: Rm: Date: Student ID # Gender Birthdate A00000 Male Female MM DD YY Student s Information: Name (please print) Street Address In case of an emergency*, notify: Name & relationship to student (please print) Street Address City State Zip Code City State Zip Code ( ) - x Phone Number Preferred address ( ) - x Phone Number Preferred address Do you plan to have a car on campus? Yes No Do you have any special physical needs? Yes No If, yes please explain Do you have special dietary needs? Yes No If, yes please explain

2 THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE APPLICANT, CIRCLE ONLY ONE RESPONSE PER LINE My class level will be: 1) New Freshmen 2) New Transfer If you are a New Transfer your classification will be: Freshman Sophomore Junior Senior Graduate *If you have a specific roommate request you must provide his/her name and address below. To have this choice accommodated your roommate choice must also request you. Name: Address: NOTE: It is required of all undergraduate students who are unmarried and financially dependent on parental support, to reside on campus. Fisk believes that participation in the give-and-take of campus life is an indispensable part of a university education. The Office of Student Engagement may make exceptions when the student is a legal resident of Davidson County, or when there is a temporary shortage of living learning center space, or due to personal circumstances. When an exception is granted, it must come in the form of written approval from the Office of Student Engagement and must be received prior to the beginning of the registration period in which the student seeks permission for off-campus residence. This contract is binding for the Academic Year (August May 2019). All students who reside in the living learning centers must sign a housing contract. I have read and retained the accompanying housing contract and agree to adhere to the regulations and agree to adhere to the rules and regulations for on-campus housing. Student Signature: Date: This application is for the Entire Academic Year. An enrolled student cannot cancel any resulting contract after August 28, 2018, unless the student graduates or withdraws before the end of the academic year I have enclosed $100 Housing Reservation Fee I have enclosed $100 Housing Deposit Business Office Receipt Certified Check (by mail only) Money Order (by mail only) Housing fees must be paid before an assignment will be made. The Office of Residence Life and Campus Services cannot process payments. All payments must be processed through the Business Office. Discrimination based on race, religion, color, national origin, sex, age, or handicap is forbidden on the campus of Fisk University. *Emergencies include but are not limited to health, safety, missing persons, and other designated emergencies. **The university cannot assume responsibility for the loss or damage to any vehicle (or its contents) operated or parked on Fisk University property. It isstrongly recommended that students living in campus housing not bring vehicles to the campus. Freshmen are especially advised against bringing their vehicles.students who bring a vehicles to campus are required to provide proof of insurance to the Office of Public Safety

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5 Lifestyle Questionnaire Fisk University Office of Residence Life and Campus Services Office (615) Fax (615) PLEASE PRINT LEGIBLY OR TYPE Student s Name Name (please print) Hometown/City and State FOR OFFICE USE ONLY Bldg: Rm: Date of Birth - - DD-MM-YYYY Address _ Do you have a specific request for a roommate? Yes No Please list his/her full name. Please note in order to be matched the request must be mutual. _ Do you have any concerns/allergies that need to be considered for housing placement? Yes No If yes, please list them Please answer the following questions, with your preference: I am a Smoker Non-Smoker I would prefer a Smoker Non-Smoker I am a Early Riser Late Riser I usually retire for the evening on average by 9pm 10pm 11pm 12pm 1am When I study I require Quiet Music Background noise When listening to music I prefer Quiet Modest Loud If available, I would prefer a co-ed floor Yes No Doesn t matter If available, I would prefer to be placed on a quiet floor Yes No Doesn t matter My house cleaning habits is relatively Clean Messy Somewhat I prefer a room temperature that is Cold Modest Hot I would prefer a room that has guests Many guests On occasion Few guests I anticipate that I will be off campus Most weekends Most weekdays Student Signature: Date: Housing fees must be paid before an assignment will be made. The Office of Student Engagement cannot process payments. All payments must be processed through the Business Office.

6 Academic Year Personal Record FISK University Office of Residence Life and Campus Services OFFICE: FAX: Date: TYPE OR PRINT LEGIBLY Name: First Middle Last 1. Home Address: Street (Rural Route) City State Zip 3. Home Telephone: ( ) 4. Sex: Male_ Female 5. If transferring, indicate college:_ 6. High School last attended: Date of Graduation 7. Clubs and activities participated in: 8. Offices held: MM YY 11. Hobbies and sports you are interested in: 12. Names of relatives who have attended Fisk: 13. Mother's or Guardian s Name: Occupation_ Place of Employment: Telephone 14. Father's or Guardian s Name:) Occupation Place of Employment: Telephone: 15. In case none of the above can be reached in an emergency give the name, address and telephone number of the nearest relative: Name:_ Relationship: Address: Telephone (_ )

7 Academic Year Health Information Form FISK University Office of Residence Life and Campus Services FAX: Date: SS # - - Student's Name Last First Middle Home (Mailing) Address Street Address City State Zip Code Emergency Contact 1: Name Telephone Relationship Emergency Contact 2: Name Telephone Relationship (Student is to complete the following questions) 1. Age Gender Date of Birth: Birthplace: MM DD YY 2. Do you have any special dietary requirements? 3. What surgical operations have you undergone? 4. Please list any medication taken regularly or occasionally: 5. Are you allergic to any medications? Yes No 6. Have you ever been treated for a nervous or emotional condition? Yes No If Yes, please explain: 7. Have you had or do you have any of the following? (Please Circle) ASTHMA SEIZURE DISORDER HYPERTENSION SICKLE CELL ANEMIA DIABETES PEPTIC ULCER MIGRAINE MIGRAINE RHEUMATIC FEVER TUBERCULOSIS HEART DISEASE Other Serious Disease or Condition: 8. Do you have health insurance/hospitalization coverage? Yes No If Yes, name of company: Policy #: Signature of Student: Date: Parent/Guardian (If student is under 18): Date: 1 of 1

8 Fisk University - Health Examination Form (PHYSICIAN IS TO COMPLETE PAGE ONE OF THIS DOCUMENT) Student's Name_ Last First Middle SS # - - Part I MMR Check appropriate box: (RUBELLA) 1. Received two (2) measles since the age of twelve months (Mo./Yr.) / (Mo./Yr.) / 2. Medically contraindicated because of pregnancy, allergy to vaccine, etc. Must list reason(s) Part II Varicella (If you were born after 1980) - Check appropriate box: 1. Dose #1 given at age 12 months or later (Mo./Yr.) / 2. Dose #2 given at age 12 months or later (Mo./Yr.) / Part II TETANUS-DIPHTHERIA Check appropriate box: 1. Completed primary series of tetanus-diphtheria immunizations (Mo./Yr.) / 2. Received tetanus-diphtheria booster within the last ten years (Mo./Yr.) / Part III MENINGOCOCCAL (A, C, Y, W) Check appropriate box: 1. One dose preferably at entry into college for freshman living in (Mo./Yr.) / residence halls, and undergraduate less than 25 years wishing to reduce their risk of disease should consider the vaccine. Part IV Please provide year when patient had the following immunizations: Typhoid (Mo./Yr.) / Whooping Cough (Mo./Yr.) / Tetanus (Mo./Yr.) / Polio (Mo./Yr.) / Measles (Mo./Yr.) / Mumps (Mo./Yr.) / Signature of Physician: Date: Name of Physician: (Please Print) PLEASE RETURN THIS FORM TO: By mail: Fisk University Office of Residence Life and Campus Services Or by fax: FAX: of 2

9 (STUDENT IS TO COMPLETE PAGE TWO OF THIS DOCUMENT) Student's Name_ Last First Middle SS # - - The General Assembly of the State of Tennessee mandates that each public of private postsecondary institution in the state provide information concerning hepatitis B infection to all students entering the institution for the first time. Those students who will be living in on campus housing must also be informed about the risk of meningococcal meningitis infection. The required information below includes the risk factors and dangers of each disease as well as information on the availability and effectiveness of the respective vaccines for persons who are at-risk for the diseases. The information concerning these diseases is from the Centers for Disease Control and the American College Health Association. The law does not require that students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or reimbursement for the vaccine. A. Hepatitis B (HBV) Immunization (TO BE COMPLETED BY ALL NEW STUDENTS) Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases. I hereby certify that I have read this information and I have received the initial dose of Hepatitis B vaccine. Date of initial does of the Hepatitis B vaccine: / / I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine. Signature of Student or Parent/Guardian (If student is under 18): Date: B. Meningococcal Meningitis -Serotype B (eg. Trumenba or Bexsero) (TO BE COMPLETED BY ALL NEW STUDENTS) Meningococcal disease is a rare but potentially fatal bacterial infection, expressed as either meningitis (infection of the membranes surrounding the brain and spinal cord) or meningococcemia (bacteria in the blood). Meningococcal disease strikes about 3,000 Americans each year and is responsible for about 300 deaths annually. The disease is spread by airborne transmission, primarily by coughing. The disease can onset very quickly and without warning. Rapid intervention and treatment is required to avoid serious illness and/or death. There are 5 different subtypes (called sereogroups) of the bacterium that causes Meningococcal Meningitis. The current vaccine does not stimulate protective antibodies to Serogroups B, but it does protect against the most common strains of the disease, including serogroups A, C, Y and W-135. The duration of protection is approximately three to five years. The vaccine is very safe and adverse reactions are mild and infrequent, consisting primarily of redness and pain at the site of injection lasting up to two days. The Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC) recommends that college freshmen (particularly those who live in dormitories or residence halls) be informed about meningococcal disease and the benefits of vaccination and those students who wish to reduce their risk for meningococcal disease be immunized. Other undergraduate students who wish to reduce their risk for meningococcal disease may also choose to be vaccinated. I hereby certify that I have read this information and I have received the vaccine for Meningococcal Meningitis. Date of Meningococcal Meningitis vaccine (Dose 1): / / Date of Meningococcal Meningitis vaccine (Dose 2): / / Date of Meningococcal Meningitis vaccine (Dose 3): / / Trumenba or Bexsero Trumenba or Bexsero Trumenba I hereby certify that I have read this information and I have elected not to receive the vaccine for Meningococcal Meningitis. Signature of Student or Parent/Guardian (If student is under 18): Date: For more information about Meningococcal Meningitis and Hepatitis B disease and vaccine, please contact your local health care provider or consult the Center for Disease Control and Prevention Web site at [ 2 of 2