Student Registration

Student's Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Please fill out this field. Please enter a phone number.
University Email Address REQUIRED Please fill out this field. Please enter an email address.
Jag Number (Student ID if you are a college student at a different univeristy) REQUIRED Please fill out this field. Please enter valid data.
Year REQUIRED Freshmen Sophomore Junior Senior Graduate Please fill out this field.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Expected graduation date (year/month) REQUIRED Please fill out this field. Please enter valid data.

Student's Address

Church Information

Have you received the sacrament of Confirmation REQUIRED Yes No Please fill out this field.
Which parish have you attended (or been registered with) before becoming a college student? Please enter valid data.

Parents information
IMPORTANT: PLEASE PROVIDE AT LEAST ONE PARENT/EMERGENCY CONTACT PERSON INFORMATION

Father's Information

Father's First Name Please enter valid data.
Father's Last Name Please enter valid data.
Father's Street Address Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Father's Phone Number Please enter a phone number.

Mother's Information

Parent's Information

Is your emergency contact one of your parents? REQUIRED Yes No Please fill out this field.
If no, please provide emergency contact information Please enter valid data.

Sacred Heart of Jesus CATHOLIC STUDENT CENTER