Office of Residence Life Housing Application 2014-2015 Academic Year

Residence Life
1100 E Sheldon BOX 6092
Prescott, AZ 86301
Fax: 928.717.7719
Office of Residence Life
Housing Application
2014-2015 Academic Year
__________________________________________________________________________________________________
(Print) Last Name
First
Middle
Y Number
Female/Male
__________________________________________________________________________________________________
Address
City
State
Zip Code
(_____)________________________ (____) ________________________
Home Phone
Birthdate:____/____/_______ Age:____
Alternate Phone/Mobile
_________________@scholar.yc.edu
Alternate Email _________________________________________________
YC Email Address All correspondence from Residence Life will be sent to you via your scholar email account. It is the responsibility of the student to check his/her
email account on a regular basis to ensure his/her account is in good standing and all deadlines are met. You may forward this account to your personal e-mail account.
Contract for:
Fall and Spring semesters
Fall semester only*
Spring semester only
*If you sign up for Fall semester only your charges will be higher
*First year freshmen are not permitted to have Fall Only contracts, freshmen are defined students with <30 credit hours completed by move-in day
Placement/Assignment
□First Year
□2nd Year □3rd Year or More
□New Student □Transfer
□Continuing
Academic Focus:
□Undeclared/General Studies
□Assoc. of Business
□Assoc. of Arts
□Assoc. of Science
□Elementary Education
□Other
Class status:
□ I prefer a double room (With roommate)
□ I prefer a single room (These smaller rooms are rare usually not available)
□ I prefer a super single A Super Single is one person in a room designed for
two. These rooms will be granted if space is available and in the order requests are
received; additional payment required.
Roommate Matching Questions:
1. Please indicate your sleeping pattern:
I like to wake up by: □6 a.m. □ 9 a.m. □Noon
I like to go to sleep by: □10p.m. □ Midnight □2 a.m. □Dawn
2. How tidy are you? □Very □ Lived in look □Messy
3. Do you smoke? □No
□Yes (all residence halls are smoke free)
4. Preferred study environment? □ Quiet □ Background noise
5. Room use: □ Study □ Socializing
Roommate request:
Their Birthdate:
All students living on campus must purchase a college meal plan. Please indicate your choice:
19 meals/week and $75.00 Roughrider Dollars per semester
15 meals/week and $100.00 Roughrider Dollars per semester
10 meals/week and $125.00 Roughrider Dollars per semester
Weekly meal counts reset each Friday.
Have you ever been convicted of (or plea bargained to) a felony or a sex offense? Choose:
YES
NO
A conviction will not necessarily disqualify an applicant from housing. Additional information may be required.
All students must submit a $50 non-refundable processing application fee and a $250 refundable housing/damage deposit with this
application in the form of a check or money order. Failure to do so will result in an incomplete application and will not be
processed.
Check #: ___________________ Please make payable to Yavapai College / in memo line write Housing Deposit
Money Order #: ___________________ Please make payable to Yavapai College 1100 E. Sheldon St. Prescott, AZ 86301
Acknowledge and Agreement
By signing this application/contract I verify I have read the Standards of Residence (www.yc.edu /residencelife) and Student Code of Conduct
(www.yc.edu/ conduct) and accept and understand all terms and conditions that apply therein. I also have read and agree to the contractual conditions
(pages 3 &4 of this application). I certify that the information I have provided is true and accurate to the best of my ability and will contact the Office of
Residence Life should I need to update any portion of the application.
I understand in order for my application to be complete all 3 of the following must be received by the Office of Residence Life:
1) a complete and signed (by the student) application, 2) vaccine records, and 3) $300 deposit.
__________________________________________________________________________________________________
Signature of Student
Date of Birth*
Date
Parent or Guardian of student under 18
I acknowledge that I have read and understand information in Section 2k of the Contract. I give permission for my student to live in a residence hall at
Yavapai College.
___________________________________________________________________________________________________
Guardian Last Name
First Name
Guardian Signature
Date
Emergency Contact
(this person may be contacted in case of a medical emergency):
__________________________________________________________________________________________________
Name
Relationship to Student
Phone #
Please list any allergies: _________________________________________________________________________
Please list current medications: ____________________________________________________________________
Medical/Mental Conditions:
Will you need any ADA accommodations? _______________________________________________________________
We encourage you to meet with our ADA Coordinator to ensure your service/needs will be met according to State/Federal regulations. Priority deadlines apply for housing. All needed
documentation should be given to the Office of Disability Resources. 928-776-2085.
Vaccination Information
The following immunization data is required for all students residing in any of the campus residences. The immunization policy is designed to protect the
health of all students. Students who fail to comply will not be permitted to enter their rooms until satisfactory completion of data.
A licensed healthcare professional care provider must certify immunization data; home records or self-reports are unacceptable. Copies of school or
military immunization records will be accepted with appropriated dates and signature indicated.
A.
B.
MMR (Measles/Mumps/Rubella)
Date of 1st MMR: ________________
Date of 2nd MMR: ________________
Meningococcal Meningitis
Date: ____________
C. Hepatitis B
Date of Dose 1: ___________
Physician’s Signature
Date of Dose 2: _________
Date
Date of Dose 3: _________
License # and Office Stamp with Address
I have read the detailed information regarding the risks of contracting meningococcal meningitis and Hepatitis B disease and the potential benefits of being
vaccination to reduce those risks.
□ I decline to be vaccinated for meningococcal meningitis.( http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.pdf)
□ I decline to receive the Hepatitis B vaccines. (http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf)
Signature of Student
Date
*Our records also require a signature of the student’s parent or guardian if the student is under 18.
Signature of Guardian
Date