Online Housing Application

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID:
Hint: Enter 7 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).

Contact Information

Local Address

Permanent Address Same as Local Address

Please describe your disability and how it will impact living on campus.
Is your condition temporary or permanent? * (Selection is Required)

Temporary

Permanent

Additional Note or Comment
Please describe the housing accommodation(s) you are requesting.
Explain how the requested accommodation will reduce the impact of your disability in campus housing.
What disability related equipment, furniture, and/or adaptive technology will you bring to your room?
Will you require assistance from emergency personnel in the event of an evacuation of the residence hall? * (Selection is Required)

Yes

No

Additional Note or Comment
Are you an incoming first year or returning student? * (Selection is Required)

First year student

Returning student

Additional Note or Comment
Do you have a current SJC housing assignment? * (Selection is Required)

Yes

No

Additional Note or Comment

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