Student Membership Form

Student Information

Please provide your contact information so that we can contact you about upcoming activities and events.

Name*

First Last

Cell*

Email*

Field of Study*

Year (Ex: 1st year undergraduate, 2 year graduate)*

Interests*

Tell us what you're interested in, so we can keep you up to speed on ongoing activities and special events:

In order for your parent's to receive our newsletter and other Newman Center updates, please fill out the following information.

First Parent Name*

First Parent Email*

Second Parent Name

Second Parent Email

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Second Home Address (if applicable)

Street Address City State / Province / Region ZIP / Postal Code