Personal Information First Name * Last Name * Student ID * Sex * Male Female Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Permanent Address * County * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP code * Student Cell Phone * Driver's License Number * Email * High School Last Attended * Country of Origin * - Select -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Parent/Guardian Name * Parent/Guardian Phone * Semester Applying For * Fall Spring Summer Year Applying For * - Select -2018-2019 Applicant Status * New Applicant Returning Applicant Share Permission By checking this box, I give permission to share my name, address, and phone number with my assigned roommate(s). Lifestyle Housing Preference Boileau Hall Greyhounds Hall Greyhound Lodge Room Temperature Preference Hot Medium Cold Sleeping and Waking I go to bed early I'm an early riser I'm a night owl I sleep late Cleanliness I'm a neat person I'm somewhere in the middle I'm a messy person Noise Level Quiet Average Loud Entertain in Dorm Room Often Sometimes Never Study Habits Frequently Occasionally Rarely Disability Housing Accommodations Yes No Disability Explanation * If Yes, please explain. Requested Roommate(s) Award Activity Scholarship Categories Men's Basketball Women's Basketball Football Rodeo Baseball Softball Trainer Spirit Squad Volleyball Fine Arts Vocal Instrumental Livestock Judging Meat Judging Theatre/Drama Men's Track & Field Women's Track & Field Women's Golf Cosmetology John Deere Other Other Categories Please notify the Dorm Office if activity scholarship is awarded after completion of Housing Application: 620-223-2700 ext. 3526 Have you ever entered a guilty plea to a felony offense, been placed on probation for or entered into a diversion program for a felony offense or been convicted of a felony? * Yes No Admissions Application * I have applied for admission and I have been accepted to Fort Scott Community College. Immunization Records * I have turned in a copy of my required immunization records. Application Fee * I understand I must contact the Fort Scott Community College business office and pay my $125 application fee. My application will not be complete until this fee has been paid. All three above requirements MUST be met before the student will be considered for placement in FSCC housing. Meeting these above requirements does not guarantee housing placement. Signature of Applicant * Date * Month MonthOct Day Day16 Year Year2018 By signing above, I authorized the above-named Parent/Guardian to obtain any information relating to my activities at Fort Scott Community College. This information may include such records as academic attendance, academic achievement, and other details pertaining to my methods/amount of payments collected or needing to be collected. Copies of this authorization are as valid as the original release signed by me. This Authorization is valid for (2) years from the date signed. Required Immunizations You are required to fax immunizations to (620) 223-4927, email them to Marci Myers at marcim@fortscott.edu, or mail them to: FSCC - Dorm Office, 2108 S. Horton, Fort Scott, KS 66701. MMR 1/MMR2 Shots Meningococcal Vaccine This documentation is required as part of a completed dorm/housing application Placement Process Prior to the beginning of the semester, applicants will be notified of room assignments. If applicants fail to receive an assignment prior to August 1, they maintain their place on the waiting list by leaving a application fee. Refunds are granted by written request only, which removes the student’s name from consideration. Once FSCC has assigned/reserved a room in your name, your application fee will not be refunded. Spring Semester application fee refunds can be processed up until January 1. Any requests made after this date will not be processed for a refund. All refunds must be requested in writing by the student through the Business Office. For refund information call (620) 223-2700, ext. 5090 or 5120 All residents are expected to comply with all policies and procedures as stated in the FSCC Dorm Handbook. FSCC has the right to refuse placement to students who have previously been placed on probation or suspension for any previous violations of the FSCC Dorm Handbook. Notice of Nondiscrimination Fort Scott Community College does not discriminate on the basis of race, color, national origin, sex, age, religion or disability in admission or access to its programs and activities. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
