Application for Housing

Application for Housing

Please complete the application below. Successful completion of this form does not reserve a room. Rooms are first come first serve once all components of the application process are complete.
Student Name*

First NameMiddle NameLast Name
If requested,I give Panola College Res Life Staff promission to share contact information with future roommates or suitmates.
Student ID#*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Ethnic Origin
Gender
Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Mobile Number*
Alt. Phone Number*
Legal Name

First NameLast Name
Preferred Name

First NameLast Name
STUDENT ID PHOTO: Please upload a headshot of yourself without sunglasses, without a hat, and with a light background, for your potential student ID card:*

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Which semester are you applying for?*
Do you have a concealed handgun license?*
First Choice Housing:
Second Choice Housing:
Would you be interested in a private room for an additional cost if availability allowed us to offer one? Private rooms are not guaranteed currently but you will be notified if they become available.
Roommate Preference:
Suitemate Preference:
Hobbies:
Major:
Are you an official member of one of the following? *
Upload your meningitis shot record below:*

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Do you have medical insurance?*

YesNo
Upload a copy of the front and back of your medical insurance card below:*

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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.
Follow the link below to fill out the Panola College Medical Waiver and upload: https://www.panola.edu/sites/default/files/2021-07/medical-waiver.pdf*

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I release this information to Panola College:*
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*
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