Housing Request Form | Mid-Carolina AHEC

Student Housing Information

Application Submission: Submit your application as soon as your rotation dates are confirmed to ensure timely processing and consideration for housing.
Notification: You will be notified if housing is available during the requested dates.
Housing Rates: Housing for out-of-state students, as well as students from private or non-state supported academic institutions, is available at a rate of $75 per week.
Contact Information: If you have any questions, please call (803) 286-4121 to speak with one of the Health Professions Student Coordinators below:

Casey Cato - ccato@midcarolinaahec.org
Sara Newton - snewton@midcarolinaahec.org

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)