Housing Cards

Email Address*
Are you a New Student or Returning Student*
What semester is this for*

First Name*
Middle Initial
Last Name*
Cell Phone Number*
Email*
Address*
City*
State*
Zip Code*
Birth Date
Gender*
Ethnic Origin*
Notify in case of Emergency
Relationship
Number (xxx-xxx-xxxx)*
Alternate Number (xxx-xxx-xxxx)
Are you allergic to any medication, food, pets, etc? If so please list:
Are you currently taking Medication?
If so please list below:
Please list all illnesses you may have:
Name of Insurance Company and Policy Number:
What activities and/or sports do you plan to participate in at Bethel?
What will be your major field of study?
Will you bring a microwave?*
Will you bring a refrigerator?*
Are you a smoker?*
Describe yourself with a short statement
Name of Roommate Preference (Optional)
Residence Hall Preference*




Signature*
Last four digits of Social Security Number*
Housing Agreement
AGREEMENT PERIOD AND PAYMENT:*
SECURITY DEPOSIT: *
HOUSING AGREEMENT CANCELLATION:*
OCCUPANCY:*
MAINTENANCE:*
VISITATION:*
SECURITY:*
RESIDENCE INSPECTION:*
DAMAGES:*
FIRE CODE REGULATIONS AND DRILLS:*
ELECTRONIC SIGNATURE:*
Please answer the simple math question below to submit the form.
2 + 2 =