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Parent/Guardian Information Form

Please submit the completed form by Friday, May 31, 2013.
An asterisk (*) indicates a required field.
Note: Please allow 72 hours for this action item to be checked off on your student's checklist.

Student Information
Student ID# * ex: 09944123
First Name *
Middle Initial
Last Name *
Nickname
Date of Birth * mm/dd/yyyy
Gender *
Home Mailing Address *

City *
State/Province/Region *
Zip/Postal Code *
Country
Home Phone *
Student Cell Phone *	If the student does not have a cell phone, please type in 0.
Fairfield University can contact me on my cell phone *	Yes No
E-mail *
Repeat E-mail *

Parent/Guardian Contact Information
	Parent/Guardian 1	Parent/Guardian 2
Prefix *
First Name *
Middle Initial
Last Name *
Suffix
Relationship to Student *
Home Mailing Address *

City *
State/Province/Region *
Zip/Postal Code *
Country
Home Phone *
Cell Phone *
E-mail *
Repeat E-mail *
Business Information
	Parent/Guardian 1	Parent/Guardian 2
Employer
Title
Occupation
Work Mailing Address

City
State/Province/Region
Zip/Postal Code
Country
Work Phone
E-mail
Repeat E-mail
Retired?	Yes No	Yes No

Volunteer Activities
	Parent/Guardian 1	Parent/Guardian 2
Volunteer Work Please List
Are you interested in getting involved in any of the following activities?
Parents' Committee Works to actively engage Fairfield parents in a variety of activities including encouraging support of the ParentsÕ Fund.		Yes No
Career Development Offer internships, job-shadow, or employment opportunities for students; participate in career panels.		Yes No
Events Represent parents at regional alumni or admissions events.		Yes No
Would you be willing to host an activity in your home or other space?		Yes No Maybe

Parent/Guardian Board Affiliations
	Parent/Guardian 1	Parent/Guardian 2
Organization One on each line
Title/Position
Organization
Title/Position
Other Information
	Parent/Guardian 1	Parent/Guardian 2
Undergraduate School/Year
Graduate School/Year
Interests/Hobbies Please List

Parent's Marital Status
Parent's Marital Status * Relative to Each Other
With Whom Does the Student Reside? *
Is Parent 1 Living? *	Yes No
Is Parent 2 Living? *	Yes No
Mother's Maiden Name *
Family Seasonal Address
Seasonal Mailing Address

City
State/Province/Region
Zip/Postal Code
Country
Phone

Other Children
	First Name	Last Name	Gender	Birthdate mm/dd/yyyy	Name of School	Year in school
Child 1
Child 2
Child 3
Child 4
Child 5

Relatives (Who Are Attending or Who Have Attended Fairfield University)
	Name	Maiden Name	Relationship to Student	Year
Relative 1
Relative 2
Relative 3
Relative 4
Relative 5
More Information
Fairfield University Bookstore Would you like to keep up to date on events, promotions, and happenings at the Fairfield University bookstore?			Yes No
Sign up for the Fairfield University Athletics E-Newsletter Looking for more detailed stories and updates about Stags sports teams? Sign up for the e-newsletter just for Fairfield Athletics, the Stags Sports Report. For more Stag Sports, visit the Stags Official Athletics site.

Security Challenge
Type the security code exactly as it appears above (case sensitive):
Note: Please do not submit this form more than once. Allow 72 hours for this action item to be checked off on your student's checklist.

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Campus Life

Support Fairfield

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Parent/Guardian Information Form

Parent/Guardian Information Form

Student Information

Parent/Guardian Contact Information

Business Information

Volunteer Activities

Parent/Guardian Board Affiliations

Other Information

Parent's Marital Status

Family Seasonal Address

Other Children

Relatives (Who Are Attending or Who Have Attended Fairfield University)

More Information

Security Challenge