Returning Student Housing Card Please Note: Fill out this form only if you have been accepted to Bethel. * Required LAST NAME* MI* FIRST NAME* Home Phone w/area code Cell Phone w/area code Email Address (Bethel e-mail only) Home Address* City* State* -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS FM GU MH MP PW PR VI AE AA AE AE AE AP INTL Zip Code* Gender Male Female Ethnic Origin Birth Date Emergency Contact Relationship Contact's Home Phone Contact's Cell Phone Contact's Work Phone Contact's Email Address I give my permission for my emergency contact to be notified in case of an emergency. Yes No Please answer the following questions to assist the Resident Life staff in various areas: Are you allergic to any medications, foods, pets, etc. I so, please list. Are you currently taking any medications? If so, please list: Please list all illnesses you may have.* Name and Policy Number of insurance company.* Name of policy holder and effective date* What activities and/or sports do you plan to partipate in at Bethel? What will be your major field of study? Will you be bringing a microwave? Yes No Will you be bringing a refrigerator? Yes No Name of roommate preference (Assignment Not Guaranteed)
