Student Housing Application

First Name*

Last Name*

CBC Student ID # (SID)*If you are an international student who has not yet received their CBC SID #, please write “F1” in the box above to notify staff to connect with the International Student Program on your application.

Permanent Address*

City*

State & Zip Code*

Note that CBC Student Housing will be communicating with you about your housing application through your email.

Cell Phone*

CBC Student Email Address*If you are an international student who has not yet received their CBC Student email, please write “F1” in the box above to notify staff to connect with the International Student Program on your application.)

Personal Email Address*

I authorize Columbia Basin College - Student Housing to share my contact information with any potential roommates to facilitate my move into Columbia Basin College’s residence hall(s)*

Yes

No

Gender*

Gender Identity*

Date of Birth*

Major*

I am in my*

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Relationship*

Street Address*

City*

State & Zip Code*

Which quarter did you want to start housing?*

Fall

Winter

Spring

Summer

Summer Internship

Please rank your room preferences (single, double, triple, quad).

Prices have been updated for the 2021-2022 academic year. *

1st choice*

2nd choice*

3rd choice*

ADA Request

Do you have any medical or physical condition(s) which requires special accommodations? This information is voluntary and will be used only to assist in making the most appropriate room assignment for you and to enable the Student Housing staff to better assist you, should an emergency arise.*

Yes

No

If yes, please list:

Have you ever been convicted of a crime: An affirmative answer to this question will not automatically preclude on campus housing.*

Yes

No

Will you be employed during the school year?*

Yes

No

If yes, when are your shifts?

Morning

Swing

Afternoon

Night

Are you a CBC student athlete?*

Yes

No

If yes, please list sport

Where do you expect to socialize most?

In other’s rooms/areas

Everywhere

Own room

Do you have any allergies?*

Yes

No

If yes, please list.

Do you have another CBC student you would like to room with?

Yes

No

If yes, list their names(s).

If you were referred to CBC Housing by a current resident, please provide their name.

Please describe your study habits.

What do you do in your free time? (hobbies, interests, clubs, etc.)?

How did you hear about us?*

If other, please specify.

Applicant represents that all of the above information and statements on the application are true. Applicant acknowledges that providing false information may be grounds for rejection of the application.

Student E-Signature*

Date*

Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and affirmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548. Individuals with disabilities are encouraged to participate in all college sponsored events and programs. If you have a disability, and require an accommodation, please contact CBC Disability Support Services at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.

Student Housing Application

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Student Housing Application