Full Name: _____________________________________________________ Date of Birth: _____________________
Address: __________________________________________________________________________________________
City/State/Zip Code:________________________________________________________________________________
Students Email Address: ____________________________________________________________________________
Home Phone: ______________________________________ Cell Phone: ____________________________________
Parent’s Name: ____________________________________ Work or Cell Phone: ___________________________
Other Contact Name: ________________________________ Phone: _____________________________________
About you:
Gender: ___ Male _____ Female ____ Transgender Male ____ Transgender Female ____ Non-binary
Program of Study (Major) _____________________________________________
Grade Level Status: ____ First-time College Student ____ Sophmore Other_________________________
Have you been placed on non-academic probation or been dismissed or suspended from another college or
university for non-academic reason, or is a disciplinary complaint currently pending against you at another
college, which might result in discipline if found guilty? ________ Yes ____________ No
Have you ever been convicted of a criminal offense other than a misdemeanor traffic violation, or are there such
charges currently pending against you at this time? ___________ Yes _ ________ No
By the signature(s) affixed below, I certify that the information provided is true and correct and that no attempt has been made to conceal pertinent
information. If any information given by me is found to be false or is an attempt on my behalf to mislead, I will be subject to eviction at any time
during my period of campus residency.
_________________________________________________ ________________________________
Student Signature Date
_________________________________________________ ________________________________
Parent or Guardian’s Signature (Required if under 19 years of age) Date
Mail this form to:
Little Priest Tribal College
601 East College, PO Box 270
Winnebago, NE 68071
Email this form to:
info@littlepriest.edu
Questions – 402-878-2380
Mark Vasina -ext. 153
Justin McCauley -ext. 104
Little Priest Tribal College does not discriminate based on race, gender, religion, national or ethnic origin, military, veteran status, political affiliation, marital status,
age, or disability in educational programs, admissions policies, employment policies, financial aid, or other College administered programs and activities. Inquiries
may be addressed to Little Priest Tribal College Title IX Coordinator for Title IX: Trisha Wegner (trisha.wegner@littlepriest.edu) and ADA, Section 504: Alysa
Turnquist (alyssa.turnquist@littlepriest.edu)– 601 East College Drive, PO Box 270, Winnebago, NE 68071.
Residence Life Application
For Office Use Only
Date Application Received________________________
LPTC Staff_____________________________________
I am planning to attend LPTC beginning (Please check one)
Fall Semester (August) Year_____________ Spring Semester(January)Year____________________
Offers are filled on a first-come, first-served basis according to the date each application is processed in the Student Accounts Office. A completed
Residence Life application does not guarantee on campus housing. Housing offers will be made by mail or electronically to e-mail (LPTC
account) to the address listed above.
All students residing in campus housing must comply with all regulations outlined in the Residence Life Handbook and maintain full-time
status of at least 12 credit hours. Little Priest Tribal College reserves the right to deny residency to any student who may create an
unreasonable risk of harm to health, safety, welfare, or prosperity of the College, members of the College, community, or him/herself.
