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Name *
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Semester/Year of Enrollment *
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Sex: *
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Male
Female
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I will be a new: *
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Transfer
Student at
Blackburn College
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Address *
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Home Phone *
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Cell Phone
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Email
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Date of Birth *
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MM
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DD
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YYYY
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Expected major area of study:
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Smoking is not allowed in any campus residence hall at any time per Illinois state law. For the purpose of allergies and/or sensitivity to
smoke, please answer the following: *
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don’t smoke and don’t want to live with a smoker.
smoke and want to live with another smoker.
don’t smoke but don’t care if I live with a smoker.
other
(please explain below #10).
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If 21 years or older, I:
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don’t drink & don’t want to live with a drinker.
drink & want to live with another drinker.
don’t drink but don’t care if I live with a drinker.
other (please
explain below).
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I usually go to bed:
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before
midnight.
around
midnight.
after midnight.
various times.
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When studying, I prefer:
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complete quiet.
moderate
noise/music.
loud
noise/music.
don’t care.
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I prefer the room to be:
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neat &
clean.
clean but not
spotless.
messy but in
organized piles.
don’t care.
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I prefer to live in a substance free/quiet environment:
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Yes.
No.
don’t care.
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Sharing:
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I share
and like people who share
It's OK, if you ask first
No sharing
please
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My social life is:
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Outgoing (I enjoy people dropping by at all times)
Moderate (I like people but need quiet time too)
Quiet and Reserved (My room is my sanctuary, I need privacy)
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Are there any particular attitudes or behaviors that make you uncomfortable?
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What are your hobbies and interests?
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Extracurricular activities:
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If you could pick the perfect roommate, what would the person be like?
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Is there anything else we should know when considering your housing assignment?
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Is there any special medical condition we need to be aware of in housing you? Physician verification may be required for any special
accommodation
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Situation:
It is the second week of school. The newness of residence hall living has worn off, and you and your roommate are beginning to settle into your customary habits.
As the days and nights pass, you become increasingly aware that your roommate doesn’t become active until later in the evening
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Which would you prefer? *
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I would definitely want my roommate to be a 'night' person
I would prefer to live with a 'night' perso, but could adjust to the reverse situation.
I would prefer to live with a 'morning' person, but could adjust to the reverse situation
I would definitely want my roommate to be a 'morning' person.
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Situation:
You are returning from the movies and find, as usual, that your roommate is entertaining a group of friends for the evening in your room. Looking for a place to
sit, you notice that the only free place is the floor. It seems that whenever you return to your room, day or night, there are at least three or four other people
there.
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Which would you prefer? *
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This situation would be very acceptable to me.
This situation would be fine occasionally.
It would be okay only when I planned to be gone from my room and my roommate let me know the visitors
were coming.
My room is my home, and I should beable to find privacy there most of the time
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I already know whom I want to room with.
(if requesting a specific roommate, he/she must also write your name on his/her form)
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Roommates name:
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Housing Options:
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Please check all that apply to your housing preference. *
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Co-Ed Dorm
Air Conditioning (extra charge will apply)
Single Sex
Dorm (male or female)
FLLC (freshman living learning community)
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Your room deposit MUST be paid BEFORE you will be assigned a room.
Assignments will be made in the order of the date room deposits are received.
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All resident students are required to participate in a meal plan—please choose your preference: *
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125 meals/semester with $150 dining dollars to be used in the snack bar or dining hall.
175 meals/semester with $75 dining dollars to be used in the snack bar or dining hall.
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