Iowa Central Application for Room & Board Contract

Application for Room and Board Contract and Room and Board Contract, conditioned upon acceptance of Application by Iowa Central Community College Residence Life Department.

The Room and Board Contract between Iowa Central Community College and applicant is for one full academic year beginning with the fall semester and ending at the end of the spring semester and academic year.

This application for Room and Board Contract will not be processed until it is fully completed by the applicant and received by Iowa Central Community College Residence Life Department with the $125 Iowa Resident or $300 Non-Resident non-refundable application fee.  Applications are processed by the Residence Life Department only during normal business hours on Monday through Friday, excluding holidays. Priority deadline for out of state residents is June 1st.

Conditioned upon Iowa Central Community College acceptance of application (as described herein), the Room and Board Contract between Iowa Central Community College and applicant is for one full academic year beginning with the fall semester and ending at the end of the spring semester or for the spring semester only (as applicant has specified above), subject to applicant complying with the Terms and Conditions of Room and Board Contract.

Any resident hall resident who does not fulfill the terms of the Room and Board Contract will be assessed a $600.00 Violation of Contract Fee.  The Violation of Contract Fee will not apply for the following reasons: marriage, death, graduation, or if the resident notifies the College that he/she will be transferring before the end of the Contract Agreement.

Conditions of Acceptance of Application:  Iowa Central Community College acceptance of this application is conditioned upon the applicant truthfully and fully providing all information requested and answering all requests, the required non-refundable application fee is received by the Iowa Central Community College Residence Life Department, and information establishes that the applicant does not have a record of criminal conviction(s), adjudication(s), plea(s), or other actions indicating behavior that could pose a risk to person and/or property and could be injurious or disruptive to the residence hall and its residents or the living environment and is not a registered sex offender.  Iowa Central Community College Residence Life Department will notify the applicant within 45 calendar days after its receipt of the application whether or not the application for Room and Board Contract has been accepted.

I understand that any non-disclosure and/or incomplete or inaccurate information by me in this application will be grounds for immediate termination of the Room and Board Contract with requirement that I vacate the premises.

Personal Information
Start Term: Please select an item.
Start Year: A value is required.
First Name: A value is required.
Middle Name/Initial:
Last Name: A value is required.
Sex: Please select an item.
Address:
City:
State:
Zip Code:
SSN:
Birthdate:
Applicants College Classification: Please select an item.
Home Phone: A value is required. Invalid format.
E-mail A value is required. Invalid format.

Parent/Guardian Information
Name:
Address:
City:
State:
Zip Code:
Home Phone:

Honor Dorm

Are you interested in living in our Honor Apartment?
Student must have a cumulative high school GPA of a 3.25 or higher. Living the Honor Dorm this may affect your roommate preference.


Roomate/Special Needs/Meal Plan
Prefered Roomate's Name:
Prefered Roomate's Academic Program:
Accomodations: Click here here if you have special needs that should be considered in making your assignment. If you need assistance or have a disability, a written description of the accommodation you request plus documentation (such as a letter of explanation from you and your health care provider) should be sent by you to Iowa Central Community College Academic Assistance & Accommodations Coordinator, attention: Samantha Reeves, One Triton Circle, Fort Dodge, IA 50501, or by email to reeves@iowacentral.edu.
Click here if you DO NOT have special needs to be considered in making your assignment
Other Questions: Have you been dismissed from a post-secondary educational institution within the past three years? Please select an item.
  If the answer is “Yes” to the above question: I state that the following reason(s) lead to the dismissal and provide the name of the educational institution:
   

By submitting this Application I authorize the above named educational institution to disclose to Iowa Central Community College’s Vice President of Enrollment Management & Student Development the information from my educational records as to the reason(s) for the dismissal.

Meal Plan Options*
Room & Board/19 meals per week - $6600.00
*subject to change after Board approval and prior beginning of contract year.


Terms and Conditions

Certification and Authorization

By submitting this form I agree to all Terms and Conditions listed below,

I certify that the above answers and the information provided herein are true and correct;

I certify that I have never entered a guilty plea to or entered an Alford Plea to or been convicted or adjudicated of a sex, domestic violence, firearms, explosive, alcohol, or drug offense or of a felony or misdemeanor offense relating to property or the person of another individual and that I am not a registered sex offender.

I authorize the educational institution, named in the answer to the post-secondary education dismissal question above, to disclose to Iowa Central Community College’s Vice President of Enrollment Management & Student Development the information from my educational records as to the reason(s) for the dismissal; and 

I authorize Iowa Central Community College Residence Life Department to conduct a detailed criminal background/history check of my past. Any criminal history data concerning me that is maintained by any federal or state agency may be released as allowed by law.

Contractual Responsibilities

By submitting this form I hereby apply for Room and Board for the academic year or the balance thereof as I have specified above.  I have read and agree to abide by the terms and conditions of the Room and Board Contract as attached.   I will send the $125 (Iowa Resident) or the $300 (Non-Resident) non-refundable application fee (as applicable) by check or money order made payable to Iowa Central Community College.  I understand that Iowa Central Community College's acceptance of this application is conditioned upon me truthfully and fully providing all information requested and answering all requests, the required non-refundable application fee is received by the Iowa Central Community College Residence Life Department, and information establishes that the I do not have a record of criminal conviction(s), adjudication(s), plea(s), or other actions indicating behavior that could pose a risk to person and/or property and could be injurious or disruptive to the residence hall and its residence or the living environment and that I am not a registered sex offender.

The $125 (Iowa Resident) or the $300 (Non-Resident) non-refundable application fee (as applicable) check or money order is payable to:
Iowa Central Community College

Send the application fee to:
Iowa Central Community College
c/o Director, Residence Life
One Triton Circle
Fort Dodge, IA 50501

Applicant Digital Signature: (enter name here to authorize):


If the applicant is under the age of 18

If the applicant is under the age of majority, the parent or guardian must also digitally sign certifying that the above answers and the information provided herein are true and correct and authorizing the educational institution, named in the answer to the post-secondary dismissal question above, to disclose to Iowa Central Community College’s Vice President of Enrollment Management & Student Development the information from the applicant's educational records as to the reason(s) for the dismissal, and authorizing Iowa Central Community College Residence Life Department to conduct a detailed criminal background check of the applicant's past.

If the applicant is under the age of majority, the parent or guardian must digitally sign as guarantor below. I understand that Iowa Central Community College's acceptance of this application is conditioned upon the applicant truthfully and fully providing all information requested and answering all requests, the required non-refundable application fee is received by the Iowa Central Community College Residence Life Department, and information establishes that the applicant does not have a record of criminal conviction(s) adjudication(s), plea(s), or other actions indicating behavior that could pose a risk to person and/or property and could be injurious or disruptive to the residence hall and its residents or the living environment and is not a registered sex offender.   In consideration of the approval of this contract between Iowa Central Community College and the applicant, I guarantee the performance of all the terms and conditions of the Room and Board Contract.


Non-Discrimination Statement
It is the policy of Iowa Central Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by the 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),  Age Discrimination Act of 1975 (34 CFR Part 110), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact Kim Whitmore, Director of Human Resources, phone number 515-574-1138, whitmore@iowacentral.edu; or the Director of the Office for Civil Rights, U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312-730-1560, fax 312-730-1576.


You must agree to the Terms and Conditions to continue. By checking the box to the left I certify that I have read and agree to the Terms and Conditions of the Room and Board Contract. The Terms and Conditions can be viewed by clicking the link to the left.