Enrollment Management
1000 West Austin, Nevada, Missouri 64772
Phone: (417) 667-8181
Fax: (417) 448-1025


On-Campus Release Form


The On-Campus Release Form is required by all students visiting the Cottey Campus. Please complete the form below prior to your visit. You will not be permitted to stay in a Residence Hall unless we have a completed and signed Release Form.

* Required fields
Name:* Email:*
Address:*
City:* State:* Zip:*
Cell #:* Home #:


Parent's or Guardians' Names:*
Address: Email:
City: State: Zip:
Home Phone #: Cell Phone #: Work #:


Who should we contact in case of an emergency?

Name:*
Phone:*
Relationship:*
Name:
Phone:
Relationship:


Are you covered by an insurance policy? * Yes No

If yes, what company? Policy Number

Are there any health conditions/allergies that we should be aware of?* Yes No

If so, what?

Please list any dietary concerns or needs:


I, the undersigned hereby acknowledge that I am the legal parent/guardian of the prospective student listed above. I authorize an official representative of Cottey College to provide first aid and/or arrange for medical
treatment, if needed.


Signature of parent or guardian:* Date:*
Reasonable care will be taken to PROVIDE a safe, protected environment for the visiting student.
Neither Cottey College nor its personnel will be liable for any loss, theft or injury incurred.





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© 2004- Cottey College   •   1000 West Austin, Nevada, Missouri 64772   •   Phone: 417-667-8181   •   Fax: 417-667-8103