Common Contracts
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Residence Hall and Food Service AgreementDecember 19th, 2016
Last Name First Name Middle Initial CUW Student ID#F00 Permanent Address City State Zip Phone( ) - Email Address Date of Birth/ / Emergency Contact Phone ( ) - Name of Emergency Contact Relationship Choose one meal plan: Additional Information included on back. 19 weekly meals/50 points 15 weekly meals/100 points 10 weekly meals/300 points 200 block meals/200 points List any health issues or disability: (documentation may be required) Health Insurance Company and Policy Number Male Female Please indicate class standing as of the first day of the term agreement: If transfer, number of semesters at previous college(s): New Freshman Transfer Graduate StudentReturning Student: (circle) Soph. Jr. Sr. International Students Only: Please list your home country Anticipated arrival date and time At your last school, were you ever subject to any disciplinary action?Yes No Describe: Have you ever been convicted of any high misdemeanor or felony? (or have a case pending) Yes NoDescribe:
