Student Information Form

Student Information Form

Health and Vehicle Information
All BMCU students must complete this form prior to August 1st. Failure to complete registration by the deadline will result in a $250 late fee.

Please complete this form in its entirety and click submit when finished. A confirmation email will be sent to your bmc.edu email.
Name*

First NameLast Name
BMCU Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Cell Number*

Country Code (1 for U.S.)Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Student ID
If you don't know your BMCU Student ID, leave blank.
Student Health Information
Emergency Contact Name*
Emergency Contact Phone Number*

Country Code (1 for U.S.)Area CodePhone Number
Second Emergency Contact Name (optional)
Second Emergency Contact Number (optional)

Country Code (1 for U.S.)Area CodePhone Number
Are you allergic to anything? (food, medication, etc.)*

YesNo
Please list all known allergies.*
Do you take any medications regularly?*

YesNo
List any medications you currently take. *
Student Vehicle Information
Resident Status*

CommuterCampus Resident
Please select your residence hall.*

WhitfieldStevensCockroftMountain VillageSouthplexLodgeCollege Houses or Loft
Vehicle Status*

I will have a vehicle on campus.I will NOT have a vehicle on campus.
If you select "I will NOT have a vehicle on campus", then the following vehicle information questions will be removed. Please sign and submit.
Vehicle Year*
Vehicle Make*
ex. Chevy, Ford, Toyota, Jeep, etc.
Vehicle Model*
ex. Silverado, Fusion, 4Runner, Wrangler, etc.
Vehicle Color*
Tag Number*
Tag County*
Tag State*
Do you have automobile insurance?*

YesNo
Do you have a handicap parking permit?*

YesNo
By signing in the box below, I warrant that all information provided above is true, complete, and accurate.*

Clear
Should be Empty:

Student Information Form

Student Health Information

Student Vehicle Information