Name:
Last First Middle

Social Security Number: Sex:
Telephone with Area Code:

Permanent Address:
Street Address
City State Zip Code

Parent or Guardian
Address (if different)
City State Zip Code

Person to notify in case of emergency

Day Phone Evening Phone

This application is for:

Fall Semester

Spring

Summer

I have lived in the Crowder College Residence halls before: Yes

I wish to have as a roommate
(If a student does not list a roommate the housing supervisor will assign a roommate based on the following information)

Major: Clubs/Organizations:

Do you belong to one of the athletic teams? Baseball Basketball

Will you be driving a car on campus? Yes

Make Model Color
Year Tag Number

A $150 ROOM DEPOSIT MUST ACCOMPANY THIS APPLICATION.
I have read and fully understand the housing rules and regulations. I voluntarily agree to live in the residence halls in accordance with all terms, conditions, and regulations established by the college and in accordance with any new regulations which may be established by the college.

Name:
Parent's Name (if student is under 18)
Date:
In the absence of a written signature, if you agree to the above terms, please select the SUBMIT button.