Application Name * First Name Last Name Preferred Name * Gender * Male Female Email * Phone * Country (###) ### #### Birthdate * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Country of Citizenship * Lease Information Estimated Move-In Date * MM DD YYYY Rate Plan * 12 Month Lease ($400 per Month) Rest of School Year Lease ($450 per Month) Month-to-Month ($500 per Month) Emergency Contact Info Emergency Contact First Name Last Name Relationship to Applicant * Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Phone * Country (###) ### #### Current Employment Current Employer * Employer Phone Number (###) ### #### Employment Position Health Information List All Allergies * List Any Physical Limitations * List All Current Medications * List Any Learning Disabilities * Do You Use Any Illegal Drugs? * Yes No Do You Smoke or Use Tobacco? * Yes No Do You Drink Alcoholic Beverages? * Yes No If You Answered Yes To Any Of The Above, Please Explain: Church Information Name of Home Church Church Address Address 1 Address 2 City State/Province Zip/Postal Code Country How Long Have You Attended? How Often Do You Attend? List Any Ministries That You Have Been Involved With Short Essay Questions Explain your relationship to Jesus Christ * What Do You Love To Do In Your Freetime? * What is your program/major at Washburn? * How did you hear about the Student Center? * Thank you! Please