First Name: Last Name: Middle Initial:

Current Address: City, State, Zip:

Email Address: Date of Birth: Male or Female:

Home Phone Number: Mobile Phone Number:

Class Standing: Major: Projected Graduation Year:

International Student (Y/N): Country:

Home Diocese: Home Parish:

Family Information

Father's Name: Mother's Name:

Father's Address: Mother's Address (If different):

Father's Phone Number: Mother's Phone Number(If different):

Which is your permanent address?

Would you permit the Newman Center Staff to inform your parents about

your positive involvement in the community?

Please let us know of anything else that can help us serve you: