Enrollment Management
1000 West Austin, Nevada, Missouri 64772
Phone: (417) 667-6010
Fax: (417) 448-1025

"C" for Yourself

The On-Campus Release and Travel 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 Form. In order to stay overnight in a Cottey residence hall, you must be a junior or senior in high school or be at least 16 years of age. Please note that while you are on campus you may not leave unless prior arrangements are made and you have notified your admission counselor.

* Required fields

Student Information

Parents or Guardians

Name:*     Names:*
Address:* Email:*
City:* Cell #:*
State:* Home #:
Zip:* Work #:
Cell #:*
Home #:

Who should we contact in case of an emergency?

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

Travel Information

Check your mode of transportation:

Fly into Kansas City (MCI) and take Cottey Shuttle
Shuttle departs from Terminal C, Gate 90 on Friday at 4:00 p.m.
Shuttle arrives at MCI Airport on Sunday at 2:30 p.m.

Rent a car - Time of arrival on campus

Drive - Time of arrival on campus

P.E.O. Sponsored trip

Arrival: Flight to Kansas City International Airport (MCI)

Airline:     Departing from:
Flight #: Arrival Date:
Terminal #: Arrival Time:
Departure: Flight from Kansas City International Airport (MCI)

Flight #:     Departure Date:
Terminal #:     Departure Time:

Guest's Name: cell #: Relationship:
Guest's Name: cell #: Relationship:
Guest Hotel/B&B:
Roommate/Suite Request:


In the event that (I/we) cannot be reached to give (my/our) consent, (I/we) the undersigned parent(s)/legal guardian(s) of a minor, hereby authorize Cottey College and/or its agents to consent for (me/us) to any x-ray, examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care deemed necessary or advisable by a licensed physician during the period (my/our) daughter * is registered for an overnight visit at Cottey College.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of Cottey College to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a licensed physician, is deemed advisable.

It is further understood that provisions of this agreement are to be used only in the event of a medical emergency to preserve the immediate well being of the named student. Any and all expenses incurred as a result of use of these provisions will be the responsibility of the undersigned individual(s).

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.

Parent's/Legal Guardian's Signature * Date *

Parent's/Legal Guardian's Signature * 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.

© 2004- Cottey College   •   1000 West Austin, Nevada, Missouri 64772   •   Phone: 417-667-6010   •   Fax: 417-448-1025