New Student Data Form - Vcu - Virginia
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1NEW STUDENT DATA FORM
Name _______________________________________________________________________________
Last
First
MI
Student ID Number
SEMESTER
YEAR _________________
Fall
Summer
Spring
Office use only
NEW NONDEGREE-SEEKING STUDENTS Please check “Yes” or “No”
RES:
Ihave been out of high school for at least one year.
Yes
No
I have been suspended from another institution within the last five years.
Yes
No
DATE OF BIRTH
I currently hold a college degree (bachelors or higher).
Yes
No
Month
Day
Year
I am registered for at least one graduate-level course (level500 or above)
Yes
No
SEX
Male
Female
I am a teacher enrolling for recertification purposes.
Yes
No.
I have applied to attend VCU in the past.
Yes
No
CITIZEN COUNTRY
US-U.S. citizen. Other than U.S., record country
I have used another name at VCU in the past.
Yes
No
Other name ______________________________________________________________________
INDICATE VISA TYPE
LOCAL ADDRESS
Street
_______________________________________________________________________________
Home State (Code VA for Virginia)
City
State
Zip
_______________________________________________________________________________
Telephone
_______________________________________________________________________________
e-mail
_______________________________________________________________________________
ETHNIC BACKGROUND (Select one or more)
PERMANENT MAILING ADDRESS
same as local address? yes
no
Are you Hispanic or Latino?
Street
_______________________________________________________________________________
Yes
City
State
Zip
_______________________________________________________________________________
No
Telephone
_______________________________________________________________________________
Select one or more of the following racial categories to describe
EMERGENCY CONTACT INFORMATION
yourself:
Name
White
_______________________________________________________________________________
Black or African American
Street
_______________________________________________________________________________
Asian
City
State
Zip
_______________________________________________________________________________
American Indian or Alaskan Native
Telephone
_______________________________________________________________________________
Native Hawaiian or Other Pacific Islander
Relationship
_______________________________________________________________________________
Records and Registration use only
Date _____________Initials_________
Office of Records and Registration
Grace E. Harris Hall
1015 Floyd Ave., 1st Floor
P.O. Box 842520
Richmond, VA 23284-2520
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