CRC Membership Application
University of Mississippi
First Name: *
Last Name: *
University of Mississippi Student ID#: *
Gender: *
Date of Birth: *
Age: *
Current Mailing Address: *
Phone Number: *
Is this a mobile number? *
Ole Miss Email: *
Marital Status: *
List all of your addictions, facilities and recovery dates: *
Do you plan live on or off campus? *
If there was a sober living option for students ON campus, would you be interested? *
If there was a sober living option for students OFF campus, would you be interested? *
What degree are you seeking? *
Have you previously attended the University of Mississippi? *
If yes, when did you last attend?
Cumulative GPA *
What does recovery mean to you? How does recovery play into all parts of your life? *
How do you maintain sobriety and participate in recovery at this time?
How do you see academics enhancing your recovery?
Provide a statement regarding your personal recovery.
What do you think will be the hardest part of sobriety and recovery while attending college at the University of Mississippi?
Please provide 3 references (name, phone and/or email)
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