Housing and Board Application - Henderson State University

Henderson State University
APPLICATION FOR Housing and board 7/16/2010
INITIALS
OFFICIAL USE ONLY BOX
DATE
This is a Legal and Binding Contract between Henderson State University and the Student.
Eligibility
A. To be eligible to live in university Housing, a student must be enrolled in at least 12 hours for credit each semester in
residence at Henderson State.
B. The University reserves the right not to contract with students who have violated the terms and conditions of the Housing
Contract, Residence Hall Lease, Residence Life Handbook, Henderson State rules and regulations, or who have a past
due balance with the university.
Name:____________________________________________________________ Date___________________
First Last Middle Initial
Email: _________________________________ Telephone Number (______) ________________
Home Address:_ ___________________________________________________________________________
Street City State Zip
Gender: o Male o Female Student ID# ________________________________
Class: o Freshman o Sophomore o Junior o Senior o Graduate
o I do not wish to be assigned to Whispering Oaks.
Are you interested in the following theme floors? If so, please rank them 1-3, with your first choice being 1.
____ First Year Experience Floor (FYE students only)
____ 24-Hour Quiet Floor - Students choosing to live on a Quiet Floor are committing themselves to living in an environment free
of loud noises 24 hours a day, providing the quietest atmosphere for studying possible.
____ Substance Free Floor - Students choosing to live on a Substance Free Floor are committing themselves to living well and
promoting healthy lifestyles by agreeing to refrain from the use of alcohol, tobacco, and other drugs.
Residence Hall Preference (if any) If so, please rank them 1-6, with your first choice being 1.
Note: Refer to http://www.hsu.edu/residence-life for information:
___ Newberry Hall (Male)
___ Smith Hall (Female)
___ East Hall (Co-ed, Upperclassman housing) ___ West Hall (Co-ed, Upperclassman housing)
___ International Student Center (International; Co-ed; Upperclassmen)
___ Sturgis Hall (Roy and Christine Sturgis Hall: The Honors College (Honors; Co-ed)
All residents must choose ONLY one meal plan:
o Basic (10 meals)
o Basic (10 meals) plus $175 Declining Cash Balance
o Standard (15 meals)
o Premium (19 meals)
o Standard (15 meals) plus $100 Declining Cash Balance
o Premium (19 meals) plus $50 Declining Cash Balance
o Unlimited Meals per week o Commuter Student Meal Plan (5 meals/wk NO HOUSING), plus
o Commuter Student Meal Plan $200 Declining Cash Balance, )
(5 meals/wk , NO HOUSING)
o NO HOUSING, MEALS ONLY
Declining Balances cannot be paid in installments and are non-refundable
I acknowledge that I have received and reviewed this Application for Housing and Board and the Residence Hall Lease and reviewed
the Residence Life handbook (available on-line as part of the HSU Student Guide) and agree that the terms and conditions contained
in all of these documents shall be incorporated into my contract for housing, if this application is approved. I further certify that all
of the representations I have made on this application and my Residence Hall lease are true and correct. I acknowledge that once
this application is accepted by the Department of Residence Life, I will be bound by a legal contract for housing and board for an
academic year unless the university releases my obligation in writing pursuant to the terms of the contract.
Signature of Student _______________________________________________________________ Date_____________________________ _
Signature of Parent/Guardian (only if student is under age 18)___________________________ Date_____________________________
Please attach a $50.00 non-refundable application fee and complete the reverse side of the contract.
This fee is due before your request will be processed.

Henderson State University
Housing Contract terms and conditions
Roommate Preference (if any): ______________________________________________ If you and another person make a reciprocal
request, both complete sets of materials must be submitted before the request can be honored.
All university residence halls are smoke free! Any health related problems, allergies (including smoke) or a physical handicap that
may affect your room assignment?_________________________________________________________________________________________
Describe yourself (pick as many as are applicable)
describe your choice of roommate:
Planned to be involved in:
“I want a roommate who is involved in”
o Varsity Sport(s) (which one)________________
o Varsity Sport(s) (which one)___________________
o Music
o Music
o Intramurals
o Intramurals
o to bed after 11:00 p.m. (weekdays)
o does not borrow my personal possessions
o to bed before 11:00 p.m. (weekdays)
o does not smoke tobacco products
o studious
o does not consume alcoholic beverages
o neat and organized
o does not play loud music
o not particularly organized
o require a lot of time to yourself
Type of music preferred:
o prefer a cool room
o Classical
o prefer a warm room
o Contemporary Christian
o smoker
o Country
o witty, humorous
o Hard Rock/ Heavy Metal
o a morning person
o Rap
o Alternative
While we make every effort to match students according to preferences, we are not always able to honor all preferences.
Contract Period
A. The period of this contract is an entire academic year consisting of fall and spring terms. If the student contracts after the beginning of the semester,
the charges will begin on the date that he/she moves into the Residence Hall. Students are expected to vacate their rooms within six (6) hours after
their last final examination each semester.
Right of Entry
The University, its officers, employees, and agents shall have the right to enter assigned rooms at reasonable times for the purpose of inspection, repair,
preservation of health, safety, quietude, recovery of Henderson owned property, and for suspected violations of the Housing Contract, Residence Hall
Lease, Residence Life Handbook, or Henderson State rules and regulations.
Termination of Contract by the Student
A. Before the lease has become binding, a student may cancel the lease by providing written notice to the Dept. of Residence Life if postmarked 30
days prior to the first day of the fall semester.
B. After 30 days prior to the first day of the fall semester, a student may request that they be released from this contract based on one of the following
reasons: unanticipated financial hardship ensuing after the start of the semester; a medical condition documented by a physician that prohibits the
student from living in the residence halls; academic internship or student teaching experience more than 50 miles from Henderson State; a change in
marital or custodial status. Students should submit their request for release from the contract to the Office of Residence Life in writing and provide supporting
documentation of the reason for their request.
Termination of the Contract by the University
The University may terminate this contract and require the student to vacate the residence hall for, but not limited to, the following reasons:
1. Failure to meet financial obligations to the University.
2. Official University disciplinary actions.
3. Failure to register for the required number of hours (12).
4. Violation of the terms of this contract, Residence Hall Lease, or Residence Life Handbook or material misrepresentations on this application.
Changes in Assignments
A. The University will not discriminate in room assignments on the basis of race, color, creed, religion, national origin, or disability.
B. Room assignments will be made at the discretion of the University on the basis of the date the lease and $50 non-refundable application fee is
received by the Dept. of Residence Life. Whenever possible, individual room assignment requests will be honored.
C. The University reserves the right to change room assignments for health, safety, repair services, economy, or disciplinary reasons involving the resident,
or for unresolvable incompatibility of roommates.
D. The University reserves the right to consolidate vacancies by requiring any resident to move from a single occupancy of double rooms to double
rooms. The resident may request permission to use a multiple occupancy room as a single room and pay the scheduled amount on a prorated basis for
the remainder of the lease.
E. The resident must vacate his/her assigned room at the closing times established by Henderson at the end of each semester and the beginning of
each vacation break period.
F. The resident may NOT change room assignments without receiving the appropriate permission in writing from their Residence Hall Director.
Please return to:
Henderson State University Residence Life Office 1100 Henderson Street – HSU Box 7533
Arkadelphia, Arkansas 71999-0001