Application for Housing
Please complete the application below. Successful completion of this form does not reserve a room. You must also submit copies of your medical insurance card and meningitis vaccination record. Rooms are first come first serve once all components of the application process are complete.
Student Name
*
First Name
Middle Name
Last Name
If requested,I give Panola College Res Life Staff promission to share contact information with future roommates or suitmates.
Please Select
Yes
No
Student ID#
*
E-mail
*
example@example.com
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
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5
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25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
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1991
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Ethnic Origin
Please Select
American Indian/Alaskan Native
Asian Pacific
Black Non-Hispanic
Hispanic
Non Resident Alien
White Non-Hispanic
Gender
Please Select
Male
Female
N/A
Preferred Pronouns
Please Select
He/Him
She/Her
They/Them
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Mobile Number
*
Alt. Phone Number
*
Legal Name
First Name
Last Name
Preferred Name
First Name
Last Name
Please upload a photo of yourself for our records
*
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Have you been tested for Covid-19 and have received a positive or are still awaiting results?
*
No
Yes
Have you been in close contact with someone who has tested positive for Covid-19 in the past 14 days?
*
No
Yes
Will you be on an airplane at any time during your travel to Panola College?
*
No
Yes
Which semester are you applying for?
Please Select
May Term
Summer I
Summer II
Fall
Spring
Do you have a concealed handgun license?
*
Please Select
Yes
No
I decline to answer
Are you a smoker?
Please Select
Yes
No
Do you stay up after 11 p.m.?
Please Select
Yes
No
First Choice Housing:
Please Select
Apartment
Traditional
O'Neal Hall
Second Choice Housing:
Please Select
Apartment
Traditional
O'Neal Hall
Roommate Preference:
Suitemate Preference:
What kind of music do you enjoy?
County
Rock
Rap
R&B
Religious
Hip Hop
Alternative
Other
Hobbies:
Major:
Are you an official member of one of the following?
Please Select
Band
Baseball
Choir
Men's Basketball
Rodeo
Theater
Volleyball
Women's Basketball
Upload your meningitis shot record below:
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of
Do you have medical insurance?
Yes
No
Upload a copy of the front and back of your medical insurance card below:
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of
List of allergies:
Please download, fill out, and return the medical coverage waiver form. The form can be found on www.panola.edu on the Residence Life & Housing webpage.
I release this information to Panola College:
Please Select
Yes
No
I understand that I must submit a copy of my meningitis shot record and a copy of my medical insurance card to complete my application.
*
I understand that Panola College reserves the right to run criminal history reports on all potential residents and that my housing application may be denied based on the results of that report.
*
Please verify that you are human
*
Submit Application
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