parents_form

Parents Record Form

This form is to be completed by parent or guardian.

Student Information

First Name:

Last Name:

Middle Name:

Preferred First Name:

High School:

High School Type:

Public school

Private School

Date Entering ECU:

Date of Birth:

Is the student transferring from another college:

Yes

No

If yes, entering ECU as a :

Freshman

Sophomore

Junior

Senior

Parent Information

Is the student under the care of :

Parent(s)

Guardian(s)

Marital Status:

Married

Divorced

Separated

Widowed

Single

Preferred address for all mailings:

Mother and Father

Mother

Father

Other

Address:

Father

Full name:

Preferred First Name:

Street Address:

Address Line 2:

City:

State/Province/Region:

Zip Code:

Country:

Employer:

Job title:

Business Address:

Undergraduate University:

Year graduated:

Other degrees, class years and universities:

Home phone:

123-456-7890

Work phone:

123-456-7890

Fax number:

123-456-7890

Preferred e-mail:

Work e-mail:

(if different from preferred)

Mother

Full name:

Preferred First Name:

Street Address:

Address Line 2:

City:

State/Province/Region:

Zip Code:

Country:

Employer:

Job title:

Business Address:

Undergraduate University:

Year graduated:

Other degrees, class years and universities:

Home phone:

123-456-7890

Work phone:

123-456-7890

Fax number:

123-456-7890

Preferred e-mail:

(if different from preferred):

Other Information

Please use the box below to list any business and civic boards and organizations to which you (father/mother) now belong:

Business, Civic Boards, Organizations:

Please use the box below to list any foundations, volunteer boards or boards of directors on which you (father/mother) have served, and where:

Foundations, Volunteer boards, Boards of Directors:

Please use the box below to list any significant former professional positions you (father/mother) have held, and where:

Professional Positions:

Relatives

Please list Relatives affiliated with East Carolina University Full name / Relation to student / Affiliation (alumnus, employee, etc.) in the box below

Relatives:

Additional Information

Additional Information:

I would like more information on serving on the East Carolina University Parents Council

I would like to be contacted to learn more about supporting East Carolina University

I have checked the information above for accuracy and hereby authorize its use by East Carolina University

*:

I agree

Parent/Guardian Questionnaire