BRERETON MANOR APPLICATION FORM

STUDENT INFORMATION

Legal Name

Preferred Name

Age and Sex

Date of Birth (mm/dd/yyyy)

Address

Street Address

City

State

Country

Postal Code

Phone *

Email *

NLC program/class

Emergency contact

Housing Request

Room preference

Move-in date

Move-out date

Vehicle/parking information

Financially Responsible Party

Responsible Party / Guarantor

Relationship to Student

Guarantor's Phone

Guarantor's Email

Guarantor's Address

Employment/income information

DOB

Screening information

Referral

Referrer's name

Agreement / Authorization *

Applicant confirms information is accurate

Screening authorization/consent

Agreement to house rules/application terms

By checking this box, I consent to receive non-marketing text messages from Brereton Manor regarding my housing application, reservation, appointment, lease, move-in information, and other service-related communications. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional text messages from Brereton Manor, including availability updates, special offers, discounts, and housing announcements. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance, reply STOP to opt out.