Conference Delegate Application (GLACURH/NACURH)

Please select the conference you are applying for: *
Name Name * First Last
Preferred Name
Pronouns (if willing to share)
Where do you live on campus? *
EIU Email *
Cell Phone Cell Phone * - ### - ### ####
Class Status: *
T-Shirt Size *
Emergency Contact Emergency Contact * First Last
Emergency Contact Relationship *
Emergency Contact Phone Number Emergency Contact Phone Number * - ### - ### ####
Insurance Provider *
Policy Number
(If EIU Student Health Insurance your policy number is your E Number) *
Insurance Provider Phone Number Insurance Provider Phone Number * - ### - ### ####
Where did hear about this leadership opportunity?

Where did hear about this leadership opportunity? RHA Meeting NRHH Meeting Panther L.E.A.D.S. Posters Other Other
Have you been to a RHA/NRHH, GLACURH, or NACURH leadership conference? *

Have you been to a RHA/NRHH, GLACURH, or NACURH leadership conference? Yes No
What do you hope to gain from going to this conference? *

What do you hope to gain from going to this conference? Connections Meeting New People From Other Schools Make New Friends Get New Experiences Visit a Different University Get More Involved Bring Something Back to EIU Get Free Stuff Other Other
In a sentence or two, answer how will going to this conference help you become a better student leader? *
Maximum of 150 characters allowed. Currently Entered: 0 characters.
What are your future plans for involvement within RHA, NRHH and/or University Housing? *
Maximum of 150 allowed. Currently Entered: 0 .
Summarize why do you think you’d be a good delegate for this conference? *
Maximum of 150 characters allowed. Currently Entered: 0 characters.
We leave on Friday afternoon and return on Sunday around noon. How do you plan to manage your schoolwork while traveling for the weekend? *
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Please list any dietary restrictions, preferences, or needs you'd like us to be aware of.
What time does your last class end on Fridays? Put N/A if you don't have any classes. *
Do you need any accommodations? (examples: technology)
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Is there anything else you'd like us to know?
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