Living/Learning Center Program Member Application

INSTRUCTIONS

Please complete a separate application for each program that you are applying to. (Tip: Use the back-space button on your Web browser to avoid having to retype the information requested in Section 1.)

Returning/Upper-Level Students should submit this application by Friday, March 11, 2005, for best consideration, although applications will continue to be accepted after that date.

Incoming First-Year and Transfer Students should submit this application by June 26, 2005.

Program descriptions can be found at: http://www.uvm.edu/llcenter/programs/

Section 1
ABOUT YOU

Please enter your full name:

First Name:

Middle Name:

Last Name:

Please enter your 9-digit UVM ID number (generally your Social Security Number). Use numbers only; no dashes.

ID Number:

Please enter your preferred e-mail address:

E-Mail Address:

Please enter your UVM Network ID, if known (e.g., gsmith, hdean, bclay1):

Net ID:

What is your gender?

Gender:

Please select your anticipated year of graduation from UVM:

Graduation Year:

Please indicate your current student status:

Status:

Academic major and minor:

Academic Major:

Academic Minor:

UVM college or school that you are enrolled in:

College/School:

Please provide your current campus address and phone (if applicable):

Room/Box Number:

Residence Hall:

Phone:

Please provide your permanent/home address and phone:

Street1:

Street2 (if needed):

City:

State:

Zip/Postal Code:

Country:

Home Phone:

Cell Phone:

Applying for admission starting which semester?

Admission semester:

Section 2
PROGRAM INFORMATION

Which program or residential TAP are you applying to?

Name of Program:

Are you applying to any other Living/Learning programs?

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If you are applying to other Living/Learning programs, what is your preference for this program?

Preference:

Are you applying to any other UVM Special Interest Housing Options?

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If you are applying to other UVM Special Interest Housing Options, what is your preference for Living/Learning?

Preference for L/L:

Please explain how your interest in this program's subject area developed, including any experience or specific skills you have which show previous involvement with the program's subject matter.

What do you hope to learn or gain from participating in this program?

What contributions will you make to help the program accomplish its objectives?

Section 3
HOUSING PREFERENCE QUESTIONS

Room size preference:

I prefer a:

If you have a roommate preference, please enter his/her name here:

Name of Preferred Roommate:

Co-ed Suite Preference:

I prefer a:

Disability Housing Accommodation:

Please check here if you currently have a disability housing accommodation or if you will be requesting a disability housing accommodation for the first time. You will be contacted by the Living/Learning Center Director's Office for additional information. All disability accommodation requests must be submitted to and certified by the UVM ACCESS Office.

PROGRAM PARTICIPATION AGREEMENT. By placing my initials below, I acknowledge that I understand that the Living/Learning Center is a unique residential learning community which seeks to integrate formal and informal learning experiences. I understand that the Center's programs need serious students who are willing to assume responsibility for their own education, and I agree to make a commitment of time and energy to this program and to the greater Living/Learning Center community if admitted. I understand that I may be removed from my room and/or relocated to another residence hall if I fail to actively participate in this program.

Please place your initials here indicating your agreement with the statement above:

Street1:
Street2 (if needed):
City:
State:
Zip/Postal Code:
Country:
Home Phone:
Cell Phone: