Student Record Form

Student Record Form
Student Record Form

Directions: Please complete this form in its entirity. This information will be kept on file in the office of Student Life. If questions do not apply to you, please indicate: N/A
Student General Information:
Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Home Address:*
City:*
State:*
Zipcode:*
Student's Cell Phone Number*

Area CodePhone Number
Student's Personal Email*
example@example.com
Current Age*
Birthday*

MonthDayYear
Date
Gender*

MaleFemale
I, the student, am:*

New incoming FreshmanTransfer studentReturning Student
I, the student, am: (please mark all that apply)*

MarriedA Parent/Legal guardian of a childIndependent (FAFSA-No FA Support from Parent/Guardian)An International StudentNone of the Above
If international student, list your home country
Health Information:
Do you have any physical or medical conditions that we need to be aware of in the event of a medical emergency?*

YesNo
If yes, please explain:
Do you take any medications on an on-going basis, that we need to be aware of?*

YesNo
If yes, please explain:
Do you have any severe allergic reactions to any of the following? Check all that apply

AspirinBee StingCodeinePenicillinAntibiotics/Sulfa DrugsNuts/DairyOther
Please explain (other):
Parent/Guardian Information
1) Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to student
(Ex: Mother, Father, Grandparent, Friend, etc.)
2) Second Parent/Guardian Name (If Applicable)

First NameLast Name
Second Parent/Guardian Phone Number

Area CodePhone Number
Second Parent/Guardian Email
example@example.com
Second Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to student
(Ex: Mother, Father, Grandparent, Friend, etc.)
Emergency Contact Information
Primary Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to student*
(Ex: Parent, Grandparent, Friend, etc.)
Secondary Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to student*
(Ex: Parent, Grandparent, Friend, etc.)
I understand that in the event of an emergency my emergency contact will be notified.*

YesNo
Note: Due to FERPA regulations, we will not communicate any academic, athletic or social information to your parent/ guardian unless we are given written permission via the FERPA Release form found in the Office of Student.
Emergency Location Information
In the event of an emergency situation that would require you to leave campus (hurricane, sickness, COVID-19 etc.), please indicate the emergency location you would go to.
Name of person you will be staying with*

First NameLast Name
Street Address:
City:*
State:*
Zip Code:*
The person at this address is my:*

Parent/guardianRelativeFriendOther
Should be Empty:

Student Record Form

Student General Information:

Health Information:

Parent/Guardian Information

Emergency Contact Information

Emergency Location Information

In the event of an emergency situation that would require you to leave campus (hurricane, sickness, COVID-19 etc.), please indicate the emergency location you would go to.