Undergraduate Summer Housing Reservation

Please complete this form no later than 4pm on Friday, April 26th, 2013.  Housing costs $105.00 per week for a double occupancy (shared) and $125.00 per week for a single/private (if available).

Last Name:        

 First Name:  

Gender:       Male Female                     

Student ID Number:                          

Phone Number:          

Email Address:      

Current Room Assignment:  

Next Fall Room Assignment:  

Home Address:

Current/Local Address:

Any Special Needs (i.e., accessibility)

Requested roommates names (if applicable)

Requesting Room Occupancy: 

Preferred Floor Level:

 CHECK WEEKS YOU WILL NEED HOUSING: 

By submitting this form, you agree to extend your 2012-2013 Housing and Dining Service Agreement with the Office of Residence Life for the Summer session. I am in acknowledgement of that my student account will be charged the total amount of my summer housing costs and that there is a $5 program fee if I intend to stay longer than two weeks this summer.