FOR OFFICIAL USE:
Building/room: _____________________
Roommate:
_____________________
Entered:
_____________________
Housing Application – Summer 2016
DATE:
_____________
Student Name:_________________________________________________________________________
(last)
Student ID:
(first)
______________________
Mailing Address:
Sex:
(middle)
_______________
DOB:
____/___/____
_________________________________________________________________
(street)
(City)
(state)
(zip)
Current Phone Numbers:
If you are a transfer student, have
you lived on campus at your previous
institution?
Home: ___________________________________________
Cell:
___________________________________________
Other: ___________________________________________
Yes
No
Please circle which college you are enrolled in:
HOSP
ARTS+SCI
BUSINESS
EDUCATION
AEP
Living / Study Habits Survey – Please complete the following survey about your living and study habits.
1.) On weeknights, I prefer to go to sleep:
a. Before midnight
b. At midnight or later
2.) Primarily, I think of my room as:
a. a place to study
b. a place for socialization and relaxation
3.) When studying in my room:
a. I prefer quiet
b. I can study with reasonable background noise
4.) Do you prefer to smoke? (NOTE: all halls are smoke-free)
a. Yes
b. No
c. Sometimes
5.) Do you prefer to live with someone who smokes?
a. Yes
b. No
May Niagara University release any of
your numbers to a roommate(s) if
appropriate?(please circle)
Yes
No
Additional information for roommate
preference:________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
_______
STUDENTS REQUESTING SPECIALHOUSING CONSIDERATION
A student with a disability requiring special housing accommodations due to his/her physical, psychological, or healthrelated impairments may request accommodations through Niagara’s Disability Services Office. Requests for
accommodations (e.g., single room, accessible room/bathroom, etc.) must be supported by documentation from a qualified
professional, and be submitted on an annual basis. Please visit http://www.niagara.edu/non-academic-accommodationssupport/ for specific directions on how to submit a disability-related housing request. The written accommodation request
and documentation of disability must be received by Disability Services by July 1, 2013. Requests received after this date can
only be considered on a space-available basis.
Personal Information / Family Members:
Parent/Guardian 1:
_________________________________________________________________
(first name)
Parent/Guardian 2
(last name)
_________________________________________________________________
(first name)
Parent/Guardian 3
(suffix)
(last name)
(suffix)
_________________________________________________________________
(first name)
(last name)
(suffix)
With whom do you live, primarily? (please circle)
Mother
Father
Neither
N/A
Emergency Contact Information: Please complete this section in its entirety
In the case of an emergency, please contact (please circle) :
Mother
Father
Contact Person’s name:
Address:
Guardian
Other:____________________
___________________________________________________________
________________________________________________________________________
Phone Number: ______________________________
Cell Number:____________________________
Email:
________________________________________________________________________
Relationship:
________________________________________________________________________
THIS APPLICATION IS DUE May 16 by noon. Please understand that the Office of Residence Life will do
our best to honor your housing request, but assignments are based on availability. Please check your
MyNU page for detailed information regarding your assignment or visit www.niagara.edu/residence-lfe
for more information on room rates and general on-campus living.
YOUR SIGNATURE:
_________________________________________________________
YOUR PRIMARY EMAIL:
_________________________________________________________
Niagara University offers a campus that brings together students, faculty and staff with diverse backgrounds, life experiences and
complex identities. Each member of this community is unique and valued. The Office and Staff of Residence Life seeks to create a
safe atmosphere based on respect and understanding within the residence halls and beyond. We believe that all members of the
Niagara Community should have an equal opportunity to learn about themselves and others within an environment that both respects
and appreciates differences. We strive to ensure that individuals are not marginalized based on their sex, race, ethnicity, nationality,
affectional/sexual orientation, religion, expression of gender identity, class, ability, age and/or veteran status.