CHHS: Living/Learning Application

Demographic Information

Last Name:	First Name:	Middle:

Preferred Name:		T-shirt Size:

WKU ID #:	Date of Birth: / /	Gender:

Street Address or PO Box:

City:	State:	Zip:

Home Phone:	Cell Phone:	Email:

Special Needs

Do you have special needs that require accommodation? (if questions call (270) 745-2992)

Please list below:

Roommate Information

Roommate Request:

Roommate WKU ID #: Please not this preference also on the Residence Hall Housing Agreement (thanks)

Academic Information

Major (if known):	High School Cumulative GPA:

Please list extracurricular activities in high school:

ACT/SAT: Score:	Are you in WKU Honors Program?

If you received Advanced Placement, CLEP or College credits, please list courses:

Essay Question

Please respond to the following essay questions. Submit typed response in U.S. Mail or via email: chhsllc@wku.edu

Why are you attending college?

What do you want to accomplish while in college?

Why do you want to be a member of the College of Health & Human Service Living/Learning Community?

What do you hope to gain from the Health & Human Services sponsored community?

Health & Human Services Agreement

My signature below (as indicated by filling in the form) indicates that I understand if selected to be a member of the College of Health and Human Services Learning Community, I will attend and participate in the activities of the program.

Name:	Date: / /

2008-2009 HEALTH & HUMAN SERVICES LIVING/LEARNING COMMUNITY APPLICATION Western Kentucky University In Partnership with

2008-2009
HEALTH & HUMAN SERVICES LIVING/LEARNING COMMUNITY APPLICATION

Western Kentucky University
In Partnership with