Check the semester you will start living in the residence hall: Fall '11 Spring '12

First Name: M.I. Last Name:
Preferred Name: Male Female Birth date: (mm/dd/yy)
Address
City State Zip
Home Phone: (###-###-####)   Cell Phone: (###-###-####)
E-mail Address:

Person to be notified in case of accident or illness:
Name Relationship Phone #

High School Graduation Date: (mm/dd/yy)
College Academic Classification:
Freshman Sophomore Junior Senior Transfer

Intended MCC Major:
Cross-Cultural Ministry Educational Ministry Family Ministry Pastoral Ministry
Youth Ministry Worship Ministry Undecided Dual-Degree with KSU

The approximate population of my hometown is: .
                          Or, I come from a rural area of people.
Home church:
What is the denomination of your home church: Assemblies of God Baptist Catholic
Christian Church Disciples of Christ Methodist Non-Denominational
Presbyterian Other:

Briefly describe your church involvement:


My current (or high school) grade point average is on a SCALE of:
I would prefer a roommate who would keep the room neat and clean. Yes No
I like to stay up late at night (past midnight). Yes No
I usually get up early in the morning (before 8:00 a.m.) Yes No
Do you consider yourself to be a fairly social person? Yes No
How do you consider yourself? Extrovert Introvert Somewhere in between
List three hobbies that you enjoy:

Do you have any physical condition which would require consideration? (i.e. knee surgery so you want 1st floor.)

Give details of any physical, mental or emotional problem(s) you have had in the last five years:

List any medications you are currently taking:

If available, would you like to be in a quiet, study-intensive suite/floor? Yes No
Other specifics you would like us to consider in matching you with a roommate:

Roommate Choices: