INSTRUCTIONS:
Print out this page. Type or Print the changed
information only (30 characters or less) in the spaces provided.
Leave all other spaces blank. Return this form to the Registrar's Office. Fax
number and address are shown above.
NAME: _____________________________ ID
NUMBER: ______ - ____ - ______
SIGNATURE: ___________________________________________________________
1.
Permanent Home Address: (LEGAL ADDRESS):
STREET ____________________________ CITY/STATE ____________________________
ZIP ____________________________
PHONE ( ) _____ - _____________
2.
Local Off-Campus Address: (COMPLETE ONLY IF DIFFERENT THAN PERMANENT):
STREET ____________________________ CITY/STATE ____________________________
ZIP ____________________________
PHONE ( ) _____ - ______________
3.
Parent/Guardian/Spouse Information:
(LAST NAME) _____________________________ (FIRST
NAME) __________________________
WORK PHONE ( ) ____ - ______
Relation (check one): 
PARENT,
GUARDIAN,
SPOUSE,
OTHER
Check if address is same as Permanent Home (#1., above)
Check if address
is same as Local Off-Campus (#2., ABOVE)
Fill in below only if NEITHER of the
above boxes is checked:
STREET ____________________________ CITY/STATE ____________________________
ZIP ____________________________
PHONE ( ) _____ - _____________
4.
Person to Notify in Case of Emergency:
Check if same
as Parent/Guardian/Spouse
Fill in below only if box above is NOT checked:
EMERGENCY NAME ________________________________
Relation(check one):
PARENT,
GUARDIAN,
SPOUSE,
OTHER
HOME PHONE ( ) _____ - ________
WORK PHONE ( ) _____ - ________
