First Name

Last Name

Gender: Male Female

Housing: dorm on-campus apartment off campus

Street Address:

City:

State: Alabama Alaska Arizona Arkansas Armed Forces Asia Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Birthday: xx/xx/xxxx

E-mail:

Home Phone (xxx) yyy-zzzz

Cell Phone (xxx) yyy-zzzz

College Attending:

Freshman Sophomore Junior Senior

Area of Study:

Hometown:

Do you have a car?

yes
no

Your Interests:

Any allergies?

Do you smoke?

Any dietary restrictions?

Refer a Friend: Name/Email of friend to be adopted with
(if applicable)