Park University Residence Life
Application for Housing Parkville, Missouri
Name
*
First Name
Last Name
Student ID Number
*
Please select one:
RETURNER: I am a returning student to Residence Life (I have lived on campus at Park before)
NEW: I am new to on-campus housing at Park
Geographic Region:
METRO AREA: My permanent address is within the KC Metro Area
OUTSIDE OF METRO: My permanent address is outside of the KC Metro Area
INTERNATIONAL: My permanent address is international
Semester Starting
*
Spring 2021
Fall 2021
Spring 2022
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Please select any student groups of which you are a member:
Baseball - Student Athlete
Basketball - Student Athlete
E-Sports- Student Athlete
Golf - Student Athlete
Honors College
International Center for Music (ICM)
International Student
Residence Life Staff
Soccer - Student Athlete
Softball - Student Athlete
Track - Student Athlete
Volleyball - Student Athlete
Other
Hall Request
Please rank the hall below based on your preference. We can not guarantee your top choice, but will take this into consideration.
1st Choice
*
Chesnut Hall
Copley Quad Hall
2nd Choice
*
Chesnut Hall
Copley Quad Hall
Roommate Request
On the lines below please write the names of your preferred roommates in ranked order. The names that you put on your list do not guarantee that you room with someone on your list. If you do not have any roommates in mind, please leave this blank
Name (1st Choice)
First Name
Last Name
Student ID Number
Name (2nd Choice)
First Name
Last Name
Student ID Number
Name (3rd Choice)
First Name
Last Name
Student ID Number
Lifestyle Questionaire
To ensure that we here at Park University Parkville are setting you up to succeed, we want to ask you some questions in order to better place you with a student that you would get along with as a roommate. Answer the following questions honestly and the best that you can!
How do you describe yourself
Morning person
Late night person
When do you usually study?
What is your anticipated major or area of study?
How clean do you like your room
Very Clean
Occasionally Messy
Pretty Messy
I have my own transportation (car, truck, etc.)
Yes
No
Emergency Contact
Much be a parent or legal guardian if under 18
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Missing Person Contact
The updated Clearly Act requires all students to provide an additional contact for the University to notify in case you go missing.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Medical History
Immunizations List dates that immunizations were received in the format (MM/DD/YY)
Tetanus, Toxoid
*
-
Month
-
Day
Year
Date
M.M.R (Measles, Mumps, Rubella):
*
-
Month
-
Day
Year
Date
Polio:
*
-
Month
-
Day
Year
Date
Diphtheria:
*
-
Month
-
Day
Year
Date
Meningitis (recommended):
-
Month
-
Day
Year
Date
Other Health Information (allergies):
Medical Provider Contact
Please provide your doctor or primary care information.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Submit Housing Application
Should be Empty: