Personal
Data
Your
First Name
Your Last Name
Middle Initial
Preferred Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
Cell Phone
Gender
Male
Female
Email
Years of College
Experience
Parent/Guardian First
Name
Parent/Guardian Last
Name
Same
Address as Student
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Email
Home Phone
Cell Phone
Work Phone
Relationship to Student
Parent/Guardian First
Name
Parent/Guardian Last
Name
Same
Address as Student
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Email
Home Phone
Cell Phone
Work Phone
Relationship to Student
Student Emergency Information
Insurance Company:
Policy Number:
Medical Conditions:
Allergies:
Current Medications
All answers are kept confidential . Please check the
most appropriate choice for each question.
Do you
smoke?
Yes
No
Would
you be willing to live with a roommate who smokes?
Yes
No
Would
you be interested in living in a substance-free area if one is
instituted?
A substance free area is a residence hall setting where
students promise to refrain from alcohol and drug use by signing a
contract.
Yes
No
Do you
have a physical/medical condition that requires special placement?
Yes
No
If yes, please describe the condition:
If your answer is yes, you will
need to mail or fax a physician’s statement to the Office of
Residence Life by June 1, 2009 for fall applicants and by December
26th for spring applicants. Fax number: 309-457-2363 Address: Office
of Residence Life, Monmouth College, 700 E. Broadway, Monmouth, IL
61462.
Do you have a disability that requires an
air-conditioner in your room? If so, for information visit
http://department.monm.edu/stuserv/student-handbook/disability-services.htm
and fill out the student disability accommodation request form
at
http://department.monm.edu/stuserv/pdf/ada-accommodation-022609.pdf .
Are
you interested in a specific roommate? That person is:
(Both persons must request each other)
For the following questions, please
click the answer that best describes you:
Prefer
room to be quiet/studious 1
2
3
4
5
See room as
lively, social center
Will
be going home every weekend 1
2
3
4
5
Will be
staying on campus Is it
important that your roommate be similar?
Yes
No
Early
Riser 1
2
3
4
5
Night Owl
Is it important that your roommate be
similar?
Yes
No
Neat
1
2
3
4
5
Untidy
Is it important that your roommate be
similar?
Yes
No
Quiet
1
2
3
4
5
Outgoing
Is it important that your roommate be
similar?
Yes
No
Select
any/all activities you plan to participate in:
Academic Interest:
Undecided
Accounting
Art
Biochemistry
Biology
Biopsychology
Business Administration
Chemistry
Classics
Communication
Computer Science
Economics
Education - Elementary
Education - Secondary
English
Environmental Science
French
History
International Business
International Studies
Management Information Systems
Mathematics
Military Science
Music
Philosophy/Religious Studies
Physical Education
Physics
Political Science
Preprofessional - Architecture
Preprofessional - Dentistry
Preprofessional - Engineering
Preprofessional -
Environmental Science
Preprofessional - Law
Preprofessional - Library Scinece
Preprofessional - Medical
Technology
Preprofessional - Medicine
Preprofessional -
Ministry/Christian Ed
Preprofessional - Nursing
Preprofessional - Occupational
Therapy
Preprofessional - Physical Therapy
Preprofessional - ROTC
Preprofessional - Social Service
Preprofessional - Veterinary
Medicine
Psychology
Public Relations
Sociology/Anthropology
Spanish
Topical Major
Theatre
Is it important that your roommate be similar?
Yes
No
Leadership Opportunities:
Leadership Selection
Academic and Professional Societies
Student Publications
Fine Arts
Student Government
Honoraries
Service Groups
Is it important that your roommate be similar?
Yes
No
Music/Theatre
Is it important that your roommate be similar?
Yes
No
Spiritual/Religious
Is it important that your roommate be similar?
Yes
No
Fraternities/Sororities
Is it important that your roommate be similar?
Yes
No
Socializing
Reading
Watching TV
Video Games
Listening to music
Favorite type:
rap
rock
country
alternative/indy
other
Scrapbooking
Outdoor activities
Running
Weightlifting
Cooking
Are you
planning on participating in Intercollegiate Athletics? If yes,
indicate which sport(s):
Varsity
Sports
Varsity Team Selection
Baseball
Basketball - Men
Basketball - Women
Cross Country - Men
Cross Country - Women
Football
Golf - Men
Golf - Women
Indoor Track - Men
Indoor Track - Women
Outdoor Track - Men
Outdoor Track - Women
Soccer - Men
Soccer - Women
Softball
Swimming - Men
Swimming - Women
Tennis - Men
Tennis - Women
Volleyball
Is it important that your roommate be similar?
Yes
No
Intramural
Sports
Is it important that your roommate be similar?
Yes
No
Residence Hall preference:
Please indicate up to
four choices, in order of preference.
1st Choice
No Preference
Bowers Hall (Jr/Sr Co-ed) *
Cleland Hall (Men)
Founders Village (Jr/Sr Co-ed) *
Fulton Hall (Women)
Graham Hall (Men)
Grier Hall (Women)
Liedman Hall (Women)
McMichael Hall (So./Jr./Sr. Women) *
Gracie Peterson Hall (Jr./Sr. Co-ed)*
North Hall (So./Jr./Sr. Co-ed) *
Winbigler Hall (Men)
2nd Choice
No Preference
Bowers Hall (Jr/Sr Co-ed) *
Cleland Hall (Men)
Founders Village (Jr/Sr Co-ed) *
Fulton Hall (Women)
Graham Hall (Men)
Grier Hall (Women)
Liedman Hall (Women)
McMichael Hall (So./Jr./Sr. Women) *
Gracie Peterson Hall (Jr./Sr. Co-ed)*
North Hall (So./Jr./Sr. Co-ed) *
Winbigler Hall (Men)
3rd Choice
No Preference
Bowers Hall (Jr/Sr Co-ed) *
Cleland Hall (Men)
Founders Village (Jr/Sr Co-ed) *
Fulton Hall (Women)
Graham Hall (Men)
Grier Hall (Women)
Liedman Hall (Women)
McMichael Hall (So./Jr./Sr. Women) *
Gracie Peterson Hall (Jr./Sr. Co-ed)*
North Hall (So./Jr./Sr. Co-ed) *
Winbigler Hall (Men)
4th Choice
No Preference
Bowers Hall (Jr/Sr Co-ed) *
Cleland Hall (Men)
Founders Village (Jr/Sr Co-ed) *
Fulton Hall (Women)
Graham Hall (Men)
Grier Hall (Women)
Liedman Hall (Women)
McMichael Hall (So./Jr./Sr. Women) *
Gracie Peterson Hall (Jr./Sr. Co-ed)*
North Hall (So./Jr./Sr. Co-ed) *
Winbigler Hall (Men)
* This residence hall has a premium
charge.
Bowers Hall additional $350 per semester
Founders Village additional $350 per semester
McMichael Hall additional $175 per semester
Gracie Peterson Hall additional $300 per semester
North Hall additional $300 per semester
My ideal roommate would have the
following qualities:
Are there particular attitudes or
behaviors that make you uncomfortable
Any additional information that should
be considered in your housing assignment