Student Name*
Student Dorm & Room Number*
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
In the event you need to quarantine or isolate (off-campus), will you move to the address listed above (home address)? * Yes No
If no, please enter the address below.
Primary mode of transportation to travel to the above address*
Secondary mode of transportation *
Name of responsible person at the address *
Phone number of responsible person at the address *( ) -
Student cell phone number*( ) -
Student alternate email address*
(email other than stevenscollege.edu)
If you do not have transportation or a secure place to move to in the event you need to quarantine or isolate, contact Mrs. Schuch (schuch@stevenscollege.edu) or Ms. Bareuther (bareuther@stevenscollege.edu).
