Housing Request Form | Mid-Carolina AHEC

Please complete all sections.
You should submit an application as soon as your rotation dates are confirmed.
You will be notified if housing is available during the requested dates.
Housing for out-of-state students, students from private or non-state supported academic institutions is provided at a rate of $75/week.

If you have any questions, please feel free to call Julie Ghent at (803) 286-4121 or email her at jughent@comporium.net

Name *

Date *

Day

Month

Year

Please Select *

Male

Female

Present Address

Address *

Address (extra field)

City *

State *

Zip Code *

Is your Permanent Address the same as your Present Address?

Yes

Permanent Address

Address

Address (extra field)

City

State

Zip Code

Phone # *

Email Address *

Emergency Contact *

Emergency Contact Phone # *

University/Department *

Degree Program *

Current year of training *

School Contact (Name, Phone #, Email)

_________________	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
_________________ Course Name and No.	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
_________________ Rotation Site/ Site Location/ Preceptor Name	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
_________________ Rotation Dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
_________________ Housing Dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)