Mohawk Valley Community College

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MVCC Community Schools Temporary Residence Application

First Name: Last Name:
Enter your full address:

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State		Zip code
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Home phone:
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Personal E-mail address: MVCC E-mail address: Date of Birth: (MM/DD/YYYY)
Gender: Male Female High School: Graduation Year: Graduation Month: Previous College Attended:

I would like to receive text messages from Mohawk Valley Community College**: Yes No

** By checking the text message opt in box you agree to receive Mohawk Valley Community College updates - recurring SMS messages containing the latest information about the school, including degree programs, scholarships, and more. Msg and data rates may apply.

Emergency Contact Name Emergency Contact Relationship: Emergency Contact Primary phone: Emergency Contact Secondary phone:

Are you presently under parole, conditionnal release, domicile restriction or cournty supervision, to include probation, conditional discharge or ACD (Adjourned in Contemplation of Dismiassal)? Yes No
Have you ever been convicted of a felony? Yes No
Have you been dismissed from a college or residence hall for other than academic reasons? Yes No
Do you have a health condtion/disability you want residence hall staff to be aware of? If so explain below. Yes No

Will you be taking any prescription medication? If so, explain below. Yes No

Please explain why you require temporary housing.

Requested Move In Date: Requested Move Out Date:

Please enter your M# in the box below labeled Signature to be your electronic signature for this form.
Signature: Date:

Reviewed By: Date:

Mohawk Valley Community College

Utica
1101 Sherman Drive, Utica, NY 13501
315-792-5400
Rome
1101 Floyd Ave., Rome, NY 13440
315-339-3470

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