Application for Residence

112 Dixie Kohn Drive, Park Hills, MO 63601

Phone: (573)518-1330

Fax (573) 518-1336

Part 1 of 2

Date:

Full Legal Name:

Address:

City:

State (ex: MO)

Zip:(5 digit/ex: 63640):

Your Cell Phone:

Secondary Phone: 

Social Security Number:

Student ID#
(Note: this is your 5-6 digit ID number. Not the same as your email login.
Example: 123456 not ab123)

Date of Birth:

Email address:

Gender:

Gender Other:

Parent/Guardian Names:

Parent/Guardian Phone Numbers:

Emergency Contact other than Parent/Guardian:

Emergency Contact Phone:

Emergency Contact Relationship:

Source of funds for housing:

Define Scholarship or Other

Special needs to be considered:

Have you ever been convicted of a felony?

Have you ever been convicted of a sexual crime?

For your room assignment:

Roommate Preference:

Contract Length:

Select your first room preference:

Major Field of Study:

Do you feel most comfortable in your room when it is neat or messy?
(Rate with 1 being neatest and 5 messiest)

Do you mind music when studying?

What type of music do you listen to?

Do you smoke?

Reminder: Smoking is not allowed anywhere on campus

Meal plan of 15 meals per week is automatically applied to all residents

You must agree to the following terms in order to submit the application:

1. All the information contained herein is correct (Failure to fully report any felony convictions
         sexual crime status will result in voiding this application and/or immediate eviction)

    2. Permission is granted to use photos for college purposes

    3. Mineral Area College is authorized to check my background information for the purpose
        of this housing

I agree to the above term:

I grant the following individuals verbal access to my information at College Park and this can only be revoked in writing (Optional - As an adult, I understand it is with my permission only that those listed be granted access. If I do NOT grant access to anyone, I must indicate with none): 

What to do next

Now that you have completed your residence application, please make a payment of $300 ($200 security deposit and a $100 non-refundable application fee).

Scholarships, grants and loans cannot cover this cost. It must be paid at the time the application is submitted.

Your accommodation is only reserved when all paperwork and payments have been submitted and cleared.

Part 2 of 2

APPLICATION FOR RESIDENCE

RESIDENT ELIGIBILITY AND BACKGROUND INVESTIGATION NOTICE

Applicants for residency to College Park are required to honestly disclose information related to their criminal history, if any. All applicant information is kept in strict confidentiality. Applicants who fail to full disclose information as requested may be refused admittance to College Park, or in the event that admittance was granted under false pretenses,may be immediately evicted from College Park. Mineral Area College reserves the right to consider criminal history information as a factor in determining eligibility for residency at College Park. Failure to fully complete Part 1 and Part 2 of the Application for Residency will result disqualification for consideration of residency at College Park.

CRIMINAL HISTORY DISCLOSURE AND BACKGROUND INVESTIGATION CONSENT

In the interests of campus and residents safety, applicants for consideration of residency at College Park must fully answer the following questions:

Have you ever been arrested or convicted of a felony, in this state or any other state?

If yes, please provide a brief description:

Have you ever been arrested or convicted of a sexual offense in this state or any other state?

If yes, please provide a brief response:

BACKGROUND CONSENT AND WAIVER FORM

As part of the process in determining my eligibility for residency at College Park, I hereby grant College Park, through the Mineral Area College Department of Public Safety, the right to conduct a background investigation to determine the veracity of my application for residency.

I understand that all information will remain strictly confidential.

I also hereby waive any and all claims for damages against Mineral Area College, its Board of Trustees or college employees, that may arise directly or indirectly as a result of information discovered or decisions made based on that information, as it pertains to my possible eligibility to be considered for residency at College Park.

This waiver shall be equally binding on my heirs, agents, representatives or assignees.

REFUND POLICY

After you have submitted this application and payment, you may cancel this agreement and have your security deposit of $200 refunded, provided you give written notification 15 days prior to semester start date.  This notification must be signed and dated by the student.

To ensure payment, please enter the name on the credit card you will be using for payment.

I have read and agree to the above background consent and waivers

Note: Before you can submit your application, you will need to review and agree to the Policies and Procedures for Students Residing in College Park.  Please click here to review.

My signature below signifies that it is my responsibility to fully read and abide by the Policies and Procedures for residents residing at College Park. I also understand that any question(s) pertaining to the clarity of College Park Policies and Procedures is to be addressed in writing directly to the Director or Assistant Director.

I also understand that failure to abide by College Park Policies and Procedures may result in disciplinary action, up to and include any of the following: warnings, fines, loss of participating privileges and/or scholarship eligibility, eviction and loss of security deposit, dismissal from Mineral Area College, and in the event of criminal wrong doing, referral for prosecution of criminal charges.

I further understand that my warnings, offenses, and violations will continue to accumulate for my entire stay at College Park as a resident, even if the resident leaves and returns in between semesters.

Name:

Date:

Please click the save button twice in order to  send a link for the application to your email

Note: If you would like to save this application and complete later, please enter your email address at the top of the form and click Save.  You will receive an email with a link to this form. 
****NOTE: SAVED APPLICATIONS WILL ONLY BE RETAINED FOR 6 MONTHS***