Known Allergies: (Please specify)

HAVE YOU EVER BEEN DIAGNOSED WITH OR HAD PROBLEMS WITH THE FOLLOWING:

Mandatory Immunizations:

The immunizations listed below are REQUIRED for students to be enrolled at FPU:

1. Completed Polio Series (3 doses of OPV or 4 doses of IPV or 4 doses of any combination of OPV and IPV; the last dose must have been given on or after the fourth birthday)

2. Completed Series of Tetanus (4 doses; last one must have been on or after the first birthday)

3. Tetanus vaccination within the last 10 years (Tdap booster, containing tetanus and reduced diphtheria toxoids and acellular pertussis strongly recommended)

4. Measles/Mumps/Rubella (MMR) 2 doses (last dose must have been after age 12 months)

5. Meningococcal Vaccine (MCV4, 2 doses if first dose was given at age 15 or younger) OR a Statement of Decline (see below)

• Re-admitted students - Please contact the FPU Health Center at (559) 453-2097 to see if updated records are required.

• International Students - In addition to the above immunizations, a negative Tuberculin Skin Test (Mantoux testing) within the last 12 months is required.

Meningitis Information

Meningococcal meningitis is a bacterial infection that can cause severe swelling of the brain and spinal cord. It is relatively rare and is often mistaken for a cold or the flu and ignored. It progresses quickly to a devastating disease with high potential for amputations, brain injury or even death. College-age students primarily living on campus have a significantly higher risk of contracting meningococcal meningitis. For this reason, the American College Health Association has adopted the guidelines adopted by the Advisory Committee of Immunization Practices (ACIP). These guidelines encourage information dissemination regarding this disease and vaccination availability to those who wish to reduce the risk of meningococcal disease.

By checking "I Agree" below I verify that

1. I have read the above message and have selected an option regarding the meningitis vaccine
2. I understand that Fresno Pacific University and the State of California requires students to provide proof of the above immunizations and I agree to submit a copy of my immunization records verifying the following immunizations: completed Polio series (3-4 doses), completed tetanus series (4 doses), 1 Tetanus-Diphtheria (TD) Booster within the last 10 years, 2 Doses of MMR (measles, mumps and rubella) at age 1 year or older, and a meningococcal vaccine or statement of decline (see check boxes above to decline).
3. I understand that if I do not turn in the required records, a hold will be placed on my registration for the following semester.

Housing Policy

The university believes that residence halls provide an educational benefit to students. The experience of living and participating in a residence hall enriches the spiritual, intellectual, emotional and physical life. It is by nature experiential. One is challenged to learn and live with others who are different from themselves. It is an opportunity to translate faith into learning and living. All students are required to live in campus housing unless they qualify for at least one of the following exemptions:

1. Living at home with their parent(s) or parental age relative
2. 21 years of age or older
3. Will be 21 within the first two weeks of the semester
4. Married or getting married before the start of the semester
5. Are a parent and primary care giver for their child
6. Carrying fewer than 9 units; or are accepted to live in an authorized residential ministry programs.

Students must demonstrate compliance with the housing policy, every year before the first day of class, by completing and submitting a Housing Policy Compliance form. Students who fail to do so will be charged the applicable room and board rate (applied to their student account) until they come into compliance with the housing policy by either moving on-campus, qualifying for an exemption listed below or successfully petitioning to live off campus.

I do not qualify for any of the previous exemptions but I would like the Housing Petitions committee to review my case as an out of the ordinary exemption.

I understand that I need to submit a letter to the Residence Life office providing the details of my request for a special exemption based on my out of the ordinary circumstance. Please note that approval for a extraordinary exemption is uncommon. Requests must be turned in to the Residence Life and Housing office in Student Life at least four weeks before the first day of class for the upcoming semester. The Housing Petitions committee will review your case within two weeks of receiving your request. (Financial difficulty does not qualify for an out of the ordinary exemption from the housing policy.)

By checking "I Agree" below I verify that

1. I have read and understand the requirements of Fresno Pacific’s Housing Policy
2. All information provided on this form is true and correct
3. I agree that if any information provided on this form changes, I will submit a new “Housing Policy Compliance” form within 2 weeks of the change
4. I agree that I will comply with Fresno Pacific’s Housing Policy.