Housing Form

Housing Form
Complete the following application.

Deposit Information
$100.00 deposit for Fall and Spring
$25.00 non-refundable deposit for summer session

If paying by money order make payable to Coahoma Community College. Please do not send cash or personal checks. If applicant fails to enroll at the scheduled time, the fee is forfeited. The fee will be refunded if the applicant is denied admission.

Deadlines: Fall - June 15 | Spring - December 15
Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Student ID Number
Activities (Check all that apply.)

BandBasseballBasketballCheerChoirFootballSoftballTrack & Field
Month and year you intend to enter Residence Hall
Do you have any chronic ailments or physical disabilities?

YesNo
Please explain.
If you have a preference of a roommate, indicate roomate's name.
I have applied for admission to Coahoma Community College.

YesNo
Have you been convicted of any felony?

YesNo
Please explain.
Insurance Information
Name of Insurance
Group Number
Policy Number
Agreement to Abide by Rules
Application Agreement
Should be Empty:

Insurance Information