Residence Hall Request

Thanks for your interest in Southeastern Community College!
We look forward to serving your educational and residential needs. Please carefully read and complete this residence hall reservation form. The required $300 deposit for accepted students confirms your attendance and reserves your placement in the residence halls. The following information is very important to us as we plan for your residential life on campus. Complete this entire form, then send a check/money order for $300 ($250 Damage Deposit/$50 nonrefundable Reservation Fee) to Residence Life Coordinator, SCC, 1500 W. Agency Road, West Burlington, IA 52655 or visit the business office to pay in person via check, cash, or credit card.

Term Applying for*

Fall/SpringFallSpring

Year Applying for*

*If you are interested in our summer housing options, please contact the Residence Life Office for the proper form.

Name*

First NameMiddle Name (If no legal middle name, please enter 'x')Last Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please include your area code and enter only numeric digits. Example 3197522731

Birth Year*

Gender Identity*

Student Status*

NewReturning

Roommate Preference (Roommate names MUST be mutually submitted.)

First NameMiddle NameLast Name

1. My music preference is

2. My sleep habits are

early to bedearly to riselate to bedlate to rise

3. I prefer a roommate from

Iowaout-of-stateoutside the U.S.I have no preference

4. I regularly study with

no noisea little background noisemoderate noise

5. I generally keep things

neatmessyin-between

6. Will you be involved in NJCAA athletics at Southeastern?

YesNo

If yes, what sport(s)?

7. How would you describe yourself?

shyoutgoingquietloud

8. I am a

smokernon-smoker

*please note that our residence halls are smoke-free

Would you prefer your roommate to have characteristics different from the ones you indicated?

YesNo

If yes, please indicate the statement number and the roommate characteristic that you would prefer.

Example: I am shy, but would like an outgoing roommate.

Request for Housing Accomodation

Southeastern Community College is aware of the importance of providing reasonable accommodations to students due to a barrier associated with a documented disability. As with all accommodations, housing accommodations are very individualized in nature and must be directly related to the impact of the student’s diagnosed disability. Student’s must complete an intake/orientation with the Accessibility Services Office and become registered with that office. Students requesting housing accommodations must submit a completed Application for Accommodations in the SCC housing environment. All disabilities must be documented by a licensed provider with expertise in the area of diagnosis. Please remember that the accommodation request is necessary to provide you an equal opportunity to enjoy student housing. The Accessibility Services Office will provide a Medical Verification form that you can take to your medical provider. The medical documentation will reside with the Accessibility Services Office due to the nature of the material shared, and confidentiality requirements. We cannot guarantee that Accessibility Services Office and Housing will be able to meet applicants late requests for accommodation needs.

Please check the box if you have a disability or special health need that should be considered while making your room assignment. Letters from you and your physician identifying the disability or special health need and your specific request MUST accompany this form. The information you provide will ONLY be used to help place you in the residence halls according to your needs and will remain in the strictest of confidence with the ResidenceLife Department at Southeastern Community College.

To request accommodations based on the impact of a disability, please contact the Accessibility Coordinator. The Coordinator can be reached by calling Angie Mickelson at 319-208-5167 or 319-313-1985 or email amickelson@scciowa.edu

Briefly indicate the condition and describe it below. The information you provide will ONLY be used to help place you in the residence halls according to your needs and will remain in the strictest of confidence with the Residence Life Department at Southeastern Community College.*

All assignments are made on a first come, first served basis.
A $300 deposit is required to reserve your room.
Residence halls are smoke-free.
Meal plans are mandatory for all West Burlington Campus SCC residents during the academic year.

Housing options are outlined below. Rates are figured per person. Please check the room option that fits you best.

Location and Occupancy*

West Burlington Campus: Double

I hereby reserve a room for housing for the academic year/term indicated on this form and will send a check or money order for $300 to cover my damage deposit and reservation fee ($50 non-refundable).
I understand that if I want to cancel my reservation, I must do so at least 30 days prior to the first day of class of the college term specified in order to receive my $250 damage deposit refund.
I also understand that if the College has no available space in the residence halls, the deposit and reservation fee (total $300) will be returned to me.

After completing this form, send a check/money order for $300 ($250 damage deposit/$50 nonrefundable reservation fee) to Residence Life Coordinator, SCC, 1500 W. Agency Road, West Burlington, IA 52655

Or visit the business office to pay in person via check, cash, or credit card.

Upon receiving your completed residence hall reservation form, the College will send you a housing and dining contract to complete and return in the postage-paid envelope accompanying the contract. You will also be sent a copy of this completed reservation form to retain for your records. After we have received your reservation form, the $300 deposit, and housing/dining contract – your file will be complete. You will receive a letter that confirms your assigned room and roommates, a copy of your contract, a bill for the amount due, and move-in information. Please note that the Residence Life Department starts making room assignments for the fall semester in July.

Email*

example@example.com

It is the policy of the Southeastern Community College not to discriminate on the basis of race, color, national origin, sex, disability, age, employment, sexual orientation, creed, religion, and actual or potential family, parental, or marital status in its programs, activities, or employment practices. If you have questions or complaints related to compliance with this policy, please contact the Director of Human Resources (employment concerns) at 319-208-5063 or the Dean of Students (student concerns) at 319-208-5101 (student concerns) at 319-208-5049, 1500 West Agency Road, West Burlington, Iowa 52655, equity@scciowa.edu or the Director of the Office for Civil Rights U.S. Department of Education, Cesar E. Chavez Memorial Building, 1244 Speer Boulevard, Suite 310, , Denver, CO 80204-3582, Telephone: (303) 844-5695 Facsimile: (303) 844-4303, TDD 800-877-8339 Email: OCR.Denver@ed.gov. Nondiscrimination statement is pursuant to requirement by Iowa Code §§ 216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.). To request accommodations based on the impact of a disability, please contact the Accessibility Coordinator. The coordinator can be reached by calling Angie Mickelson at 319-208-5167 or 319-313-1985 or email amickelson@scciowa.edu

Signature*

Residence Hall Request

Personal Information

Student Characteristics

Residence Hall Housing Options

Contractual Responsibilities

The Next Step